Cross-sectional survey of anaesthesia and analgesia protocols used to perform routine canine and feline ovariohysterectomies.

OBJECTIVE: To collect baseline descriptive data on the anaesthesia and analgesia protocols used by New Zealand veterinarians in first-opinion practice when performing routine canine and feline ovariohysterectomies. STUDY DESIGN: Cross-sectional survey. ANIMALS: Not applicable. METHODS: An online survey was conducted asking respondents for: 1) preoperative patient assessment; 2) preanaesthetic medication and induction drugs used; 3) anaesthesia maintenance drug choices and monitoring equipment used; and 4) postoperative analgesia drug selections and monitoring for ovariohysterectomy performed in healthy adult dogs and cats. RESULTS: The survey was completed by 472 veterinarians, of whom 282 provided responses for canine ovariohysterectomy and 361 provided responses for feline ovariohysterectomy. Approximately 23% of canine ovariohysterectomies and 13% of feline ovariohysterectomies had preanaesthetic bloodwork performed. There were 74 unique premedication/induction drug combinations reported for canine ovariohysterectomies and 94 for feline ovariohysterectomies. The most commonly used drug combinations were acepromazine, morphine ± propofol and butorphanol, ketamine and medetomidine for canine and feline ovariohysterectomies respectively. Most animals were intubated, and anaesthesia was maintained with isoflurane in oxygen. Use of intravenous catheters, fluid administration, heat support, and monitoring equipment varied. There were 41 unique postoperative analgesia drug combinations reported for canine ovariohysterectomies and 20 for feline ovariohysterectomies. Canine ovariohysterectomies were most commonly administered injectable opioids on the day of surgery followed by 3 days of oral non-steroidal anti-inflammatory drugs (NSAIDs), whereas feline ovariohysterectomies were usually administered a single injection of an opioid or NSAID or both on the day of surgery. Most animals were seen within 7-10 days for re-examination and/or suture removal. CONCLUSIONS AND CLINICAL RELEVANCE: Veterinarians use a wide range of anaesthesia and analgesia protocols for routine ovariohysterectomies. Further research is needed comparing the safety and efficacy of commonly used protocols to determine whether there are opportunities to improve the level of patient welfare.

Experience of Practicing Veterinarians with Supervising Final-Year Students and New Graduates in Performing Desexing Surgeries.

With increasing pressure on university teaching hospital caseloads, veterinary students are increasingly being taught basic desexing skills during their final-year extramural rotations or as new graduates in practice. A cross-sectional survey of New Zealand veterinarians was conducted to elicit information about their experiences supervising these cohorts. Of the 162 respondents who had supervised at least one final-year veterinary student, only 95 (58.6%) allowed students to perform desexing surgeries and the most common procedures they allowed students to perform were cat neuters (96%) followed by cat spays (64%), dog neuters (63%), and dog spays (24%). The time needed to supervise students, the liability of students operating on client-owned animals, and students' poor basic instrument, tissue, and suture handling skills were cited as major deterrents. Breaks in sterility and dropped pedicles were the most frequently reported complications, although these still occurred only occasionally or rarely. Of the 101 respondents who had supervised at least one new graduate, all but one provided surgical mentoring. It took an average of 3.3 dog neuters, 8 dog spays, 2.4 cat neuters, and 4.7 cat spays before respondents were comfortable letting new graduates perform surgery unassisted. Respondents generally expected new graduates to perform dog spays in under 60 minutes, cats spays and dog neuters in under 30 minutes, and cat neuters in under 10 minutes. Although most respondents agreed that students needed more hands-on experience with live animal surgery, the main clinical skills deficiencies identified were ones that could easily be trained and practiced on simulated models.

Guidelines for Implementing a Low-Cost Volunteer Desexing Skills Training Program for Veterinary and Veterinary Technology Students.

Although desexing surgeries are considered a core clinical skill for small animal veterinary practice, it can be challenging for veterinary schools to provide students with adequate training opportunities in the traditional curriculum. At the Massey University School of Veterinary Science, we recently established an innovative extracurricular volunteer program designed to have students teaching other students how to perform different elements of desexing procedures as they progress through their degree. This program includes administrative and assistant roles for first-year students (responsible for client communication, patient restraint, and medical record keeping), physical exam and recovery roles for second-year students (responsible for assessing patient fitness for surgery, drawing up anesthetic drugs, and monitoring patients in recovery), anesthesia and neuter surgeon roles for third-year students (responsible for inducing, preparing, and monitoring spay patients and performing cat neuter surgeries), and spay surgeon roles for fourth- and fifth-year students (responsible for performing cat spay surgeries, discharging patients, and following up with clients to monitor recovery). This program has been successful in improving student confidence and competence while also providing a valuable low-cost desexing service to the community. In this article, we discuss the practical considerations and processes involved in implementing this program, including mapping the existing surgical curriculum, recruiting patients, setting up the surgical facilities, purchasing equipment and supplies, establishing standard operating procedures, developing training materials, maintaining clinic records, and monitoring program outcomes. These resources can serve as guidelines for other veterinary schools looking to expand desexing surgery training opportunities for students.

Predictors of Long-Term Mortality in Patients Hospitalized in an Intensive Cardiac Care Unit.

Patients admitted to an intensive cardiac care unit (ICCU) are a heterogeneous population with a high mortality rate. The aim of our study was to investigate which clinical, biochemical, and echocardiographic parameters routinely assessed may affect long-term mortality in a non-selected ICCU population.A total of 392 patients hospitalized between 2008-2011 (mean age, 70 ± 13.8 years, 43% women) were consecutively and prospectively assessed with the following admission diagnoses: 168 with acute coronary syndromes (ACS), 122 with acute decompensated heart failure (ADHF), and 102 with other acute cardiac disorders. Patients were treated according to the current European Society of Cardiology (ESC) guidelines.During a mean 29.3 (± 18.9) months of observation, 152 (38.8%) patients died and 7.9% of the patients needed a red blood cell transfusion (RBC Tx). Patients who died were significantly older and had lower baseline levels of hemoglobin (Hb), serum iron concentration (SIC), total iron binding capacity (TIBC), cholesterol, and left ventricular ejection fraction (LVEF), as well as lower eGFR values, and higher white blood cell (WBC) counts and C-reactive protein (CRP) levels (P < 0.05). Predictors of death in multivariate regression analysis were age, Hb, LVEF, WBC, and CRP. The most powerful factor was hospitalization for non-ACS. The risk of long-term mortality increased with decreasing levels of Hb (P < 0.001), SIC (P = 0.001), TIBC (P = 0.009), and the need for RBC Tx (P < 0.001), as well as the diagnosis of ADHF (P < 0.001) and the absence of ACS (P = 0.007).In ICCU patients, age, Hb, parameters of iron status, and LVEF are strong predictors of long-term mortality. Among the ICCU population, patients with ACS diagnosis have better survival.

Is real time contrast echocardiography useful for assessment of the right ventricular morphology, function, and perfusion?

BACKGROUND: Contrast-enhanced echocardiography (CE) is recommended to assess left ventricular function and perfusion but is rarely used to assess the right ventricle (RV). We used CE to assess RV function and perfusion and evaluated whether RV perfusion defects varied in different patient groups with RV failure due to pressure overload. METHODS: We studied 17 patients with acute pulmonary embolism (PE), 19 patients with chronic pulmonary arterial hypertension (CPH), and 7 healthy volunteers. The examination included RV opacification (RVO) and myocardial CE. RV end-diastolic area (RVEDA), RV end-systolic area (RVESA), fractional area change (FAC), and wall-motion score index (WMSI) were assessed before and after contrast agent administration. Perfusion was evaluated qualitatively and quantitatively. RESULTS: RVEDA, RVESA, FAC, and regional contractility were comparable before and after contrast agent injection. Significant perfusion defects were seen in PE and CPH (18/39 segments and 37/51 segments, respectively, vs. 0/21 segments in healthy volunteers; P < 0.0001). Wall-perfusion score index (WPSI) was higher in PE and CPH compared to healthy volunteers (1.5 ± 0.3 and 1.8 ± 0.4 vs. 1.0 ± 0.0; P = 0.02 and P = 0.0003, respectively). Linear correlations were noted between WMSI, FAC and WPSI (r = 0.5, P = 0.014 and r = -0.55, P = 0.005, respectively). Quantitative perfusion assessment revealed perfusion defects in the apical segment in the PE group. The mean region of interest value was insignificantly reduced in PE and CPH groups. CONCLUSION: Contrast-enhanced echocardiography is feasible and may be useful for RVO and perfusion assessment in patients with RV dysfunction due to systolic overload. The SonoVue contrast agent was well tolerated by stable patients with PE and CPH.

Pentraxin 3 as a marker of development and severity of stable coronary artery disease.

PURPOSE: Inflammation plays a crucial role in the development of atherosclerotic plaques. Pentraxin 3 (PTX3) is produced at the site of inflammation and has been identified as a specific marker of atherosclerosis, vascular inflammation, and progression of the coronary artery disease (CAD). The aim of the study was to establish if PTX3 has potential relations with classical markers of cardiovascular risk, and if PTX3 may act as an independent risk factor of CAD occurrence and advancement. MATERIALS AND METHODS: The study included 98 patients with stable CAD confirmed in coronary angiography (CAD group) (median age 65 interquartile range [IQR] 61-72 years; 72% men). The control group consisted of 40 patients without CAD. RESULTS: The CAD group had significantly higher PTX3 concentration compared to the control group. There was a correlation with age, male gender, lipid profile and intima-media thickness. There was no correlation between PTX3 concentration and the number of coronary vessels with significant atherosclerotic lesions and the advancement of atherosclerotic lesions on the Gensini scoring scale. The cut-off point was determined for 0.89 ng/ml for the exclusion of angiographically significant atherosclerotic lesions. CONCLUSIONS: Patients with CAD have significantly higher concentration of PTX3. There was no correlation between PTX3 and the advancement of angiographically significant atherosclerotic lesions in coronary arteries. Low PTX3 concentration may serve as an indicator for the absence of atherosclerosis.

A 39-Year-Old Woman with Ventricular Electrical Storm Treated with Emergency Cardiac Defibrillation Followed by Multidisciplinary Management.

BACKGROUND Ventricular electrical storm (VES) is a treatment-resistant ventricular arrhythmia associated with high mortality. This report is of a 39-year-old woman with VES treated with emergency cardiac defibrillation followed by multidisciplinary management. CASE REPORT A 39-year-old woman, previously diagnosed with eosinophilia of unknown origin and recurrent non-sustained ventricular tachycardias, was admitted to the Department of Invasive Cardiology with VES after an initial antiarrhythmic approach, analgesia, and defibrillation in the Emergency Department. The patient had a temporary pacing wire implanted, but overdrive therapy was not successful. The medical treatment and multiple defibrillations did not stop the arrythmia. Due to the hemodynamic instability, extracorporeal membrane oxygenation (ECMO) was performed at the Department of Cardiac Surgery. Consequently, the patient was stabilized and an electrophysiology exam and RF ablation of arrhythmogenic focus were conducted in the Department of Cardiology. One day after the procedure, the patient had pulmonary edema caused by pericardial tamponade. The patient was successfully operated on in the Department of Cardiac Surgery. Then, the next complication appeared - a femoral artery embolism - which was treated in the Department of Vascular Surgery. After patient stabilization and exclusion of serious neurological damage, an implantable cardioverter-defibrillator (ICD) was implanted for secondary prevention of sudden cardiac death (SCD). CONCLUSIONS This case has shown the importance of the rapid diagnosis of VES and emergency management with cardiac defibrillation. Multidisciplinary clinical follow-up is required to investigate and treat any reversible causes and to ensure long-term stabilization of cardiac rhythm.

Insulin-Like Growth Factor-Binding Protein 7 (IGFBP-7)-New Diagnostic and Prognostic Marker in Symptomatic Peripheral Arterial Disease?-Pilot Study.

The aim of our study was to evaluate the importance of insulin-like growth-factor-binding protein 7 (IGFBP-7) as a potential marker of symptomatic peripheral artery disease (PAD) occurrence. The study group consisted of 145 patients with diagnosed PAD, who qualified for the invasive treatment. The control group consisted of 67 individuals representing the local population and an ischemic heart disease (IHD) group of 88 patients after myocardial infarction or percutaneous coronary intervention. Patients with PAD had significantly higher IGFBP-7 concentrations than control group (1.80 ± 1.62 vs. 1.41 ± 0.45 ng/mL, p = 0.04). No significant differences between PAD patients and IHD patients were found (1.80 ± 1.62 vs. 1.76 ± 1.04 ng/mL, p = 0.783). Patients with multilevel PAD presented significantly higher IGFBP-7 concentrations than patients with aortoiliac PAD-median 1.18 (IQR 0.48-2.23) vs. 1.42 ng/mL (0.71-2.63), p = 0.035. In the group of patients who died or had a major adverse cardiovascular event (MACE) during six months of follow-up, a statistically significant higher IGFBP-7 concentration was found (median 2.66 (IQR 1.80-4.93) vs. 1.36 ng/mL (IQR 0.65-2.34), p = 0.004). It seems that IGFBP-7 is elevated in patients with atherosclerotic lesions-regardless of their locations. Further research should be conducted to verify IGFBP-7 usefulness as a predictor of MACE or death.

Salivary Gland Dysfunction in Patients with Chronic Heart Failure Is Aggravated by Nitrosative Stress, as Well as Oxidation and Glycation of Proteins.

Chronic heart failure (HF) is an important clinical, social, and economic problem. A key role in HF progression is played by oxidative stress. Free oxygen radicals, formed under the conditions of hypoxia and reperfusion, participate in myocardial stunning and other forms of post-reperfusion damage. HF patients also suffer from disorders connected with saliva secretion. However, still little is known about the mechanisms that impair the secretory function of salivary glands in these patients. In the presented study, we were the first to compare the antioxidant barrier, protein glycoxidation, and nitrosative/nitrative stress in non-stimulated (non-stimulated whole saliva (NWS)) and stimulated (SWS) saliva of HF patients. The study included 50 HF patients with normal saliva (NS) secretion (n = 27) and hyposalivation (HS) (n = 23), as well as an age- and gender-matched control group (n = 50). We demonstrated that, in NWS of HF patients with HS, the concentration of low-molecular-weight non-enzymatic antioxidants decreased (↓total polyphenols, ↓ascorbic acid, ↓reduced glutathione, ↓albumin) compared to HF patients with normal saliva (NS) secretion, as well as the control group (except albumin). We also observed increased content of protein glycoxidation products (↑dityrosine, ↑kynurenine, ↑glycophore) in NWS and SWS of HF patients with HS compared to healthy controls. Interestingly, the content of dityrosine, N-formylkynurenine, and glycophore in NWS was also significantly higher in HF patients with HS compared to those with NS secretion. The concentration of NO was considerably lower, while the levels of peroxynitrite and nitrotyrosine were significantly higher in NWS and SWS of HF subjects with HS compared to the controls. Salivary gland dysfunction occurs in patients with chronic HF with the submandibular salivary glands being the least efficient. Oxidative/nitrosative stress may be one of the mechanisms responsible for the impairment of salivary gland secretory function in HF patients.

Coronary blood flow in patients with end-stage renal disease assessed by thrombolysis in myocardial infarction frame count method.

BACKGROUND: Myocardial ischaemia in patients with end-stage renal disease (ESRD) develops both due to the epicardial coronary artery stenosis and to the microvascular injury. We aimed to evaluate coronary blood flow in ESRD patients by means of the thrombolysis in myocardial infarction (TIMI) frame count method (TFC). In patients with ESRD, implementation of the TFC as a marker of the coronary flow abnormalities have not been previously investigated. METHODS: Thirty-nine ESRD patients on regular dialysis underwent elective coronary angiography. Coronary artery stenosis >75% was defined as significant. TFC for the three main coronary vessels was calculated. Higher TFC values reflected slower flow. RESULTS: In 19 patients (49%), significant epicardial coronary artery disease was found. Distribution of the TFC for the three main coronary arteries reflected prevalence for higher TFC values. Mean corrected TFC for the left anterior descending artery (LAD) was 34.7 +/- 16, for the circumflex artery (Cx) 41.5 +/- 25 and for the right coronary artery (RCA) 30.9 +/- 18 frames. For the three main coronary vessels, there were no statistically significant differences between the mean TFC values according to the presence or absence of the severe coronary artery stenoses on angiography (LAD: 30.2 +/- 12 vs 36.3 +/- 18; Cx: 41.5 +/- 20 vs 41.5 +/- 27; RCA: 34.9 +/- 16 vs 30.0 +/- 19, respectively). CONCLUSIONS: Our results demonstrate for the first time the reduction in blood flow velocity, assessed with TFC method, in the coronary arteries of ESRD patients. This phenomenon was observed regardless of the presence of the significant epicardial coronary artery stenosis. Therefore, TFC cannot be applied as a marker of significant coronary artery stenosis in ESRD population.

Apelin: a novel marker for the patients with first ST-elevation myocardial infarction.

To date, only animal studies have been concerned with apelin involvement in acute myocardial ischemia. The aim of this study was to investigate apelin measurements in low-risk patients with first ST-elevation myocardial infarction (STEMI) and to assess if apelin may feature as a marker of left ventricular (LV) injury and prognosis. In 78 consecutive patients (mean age 67 +/- 11.5 years, 24 women) with first STEMI treated with primary percutaneous coronary intervention, plasma apelin-36 concentrations were measured twice: on admission and on the 5th day of hospitalization. Left ventricle ejection fraction (LVEF) was applied as marker of LV injury. Composite endpoint (CEP), which included death, stroke, and recurrent ischemic event, was assessed after 1 year follow-up. On the first day, median apelin-36 concentration was 2138.5 pg/ml and on the 5th day was significantly lower, 2008.3 pg/ml (P = 0.002). There were no significant differences found in apelin-36 concentrations between patients with normal and low LVEF. In both groups significant reductions were found in apelin-36 concentrations measured in 5-day intervals (P = 0.04 and P = 0.008, respectively). After a 1-year follow-up, only one patient died and 19 patients (24.3%) had reached CEP. No difference in baseline apelin-36 concentrations were found in the group of patients who reached CEP compared with those without CEP. However, in both groups concentrations significantly decreased after 5 days (P = 0.04 and P = 0.013, respectively). Apelin-36 concentrations are reduced in low risk first STEMI patients during the first days regardless of the degree of LV dysfunction and prognosis.

Influence of atorvastatin on blood pressure control in treated hypertensive, normolipemic patients - An open, pilot study.

AIMS: The aim of the study was to determine whether a high dose of atorvastatin lowers blood pressure (BP) in normolipemic patients with well controlled primary arterial hypertension and if this effect is associated with alteration of biomarkers of endothelial function and oxidative stress. In this open-label study, normolipemic patients (n=56) were randomized in the proportion of 2:1 to receive atorvastatin 80 mg daily for 3 months (statin-treated, ST n=39), or to previous therapy (statin-free, SF). BP was measured using a 24-h ambulatory BP measurement device. Plasma levels of 6-keto-PGF(1alpha) (prostacyclin metabolite), serum nitric oxide (NO) and levels of autoantibodies immunoglobulin G against oxidatively modified low-density lipoprotein (ox-LDL) were measured. MAJOR FINDINGS: The mean change in systolic BP and diastolic BP for ST was - 5.7 mmHg (95% CI -4.1 to -7.2 mmHg) and -3.9 mmHg (95% CI -2.7 to -5.0 mmHg), respectively. Hypotensive statin effect was independent of lipid lowering. No change of BP in SF patients was observed. In ST, prostacyclin metabolites and NO concentrations were not significantly increased and autoantibodies against ox-LDL concentrations did not change. In ST, the decrease in BP correlated with increase in NO and decrease in autoantibodies against ox-LDL. PRINCIPAL CONCLUSION: High-dose atorvastatin resulted in reduction of BP independently of lipid-lowering effect, changes in endothelial function and oxidative stress, but it was related to the increase in NO and decrease in autoantibodies against ox-LDL. However, because of the open design of the study, these results should be carefully debated.

Endothelial dysfunction and sympathetic nervous system activation in young patients with essential arterial hypertension and without hypercholesterolaemia.

OBJECTIVE: The aim of the study was to evaluate whether measurements of hs-C-reactive protein (hs-CRP), endothelin-1 (ET-1), epinephrine (E) and norepinephrine (NE) would provide useful information for the assessment of endothelial dysfunction and sympathetic nervous system activation in a selected group of young, properly treated patients with essential arterial hypertension (HTN) and without hypercholesterolaemia. METHODS AND RESULTS: Serum hs-CRP and ET-1 as well as plasma epinephrine and norepinephrine concentrations were measured in 134 subjects (62 patients with diagnosed HTN and 72 healthy subjects from a reference group). In patients the concentrations of hs-CRP, ET-1 and NE were significantly higher, than in healthy subjects. The highest diagnostic sensitivity (87%; 95% CI 76.1-94.2) was found for serum hs-CRP; the highest diagnostic specificity (96%; 95% CI 88.3-99.1) and positive predictive value (89%) were found for ET-1 measurements. The analysis of logistic regression showed that the highest risk of HTN was found for the patients with high levels of ET-1, hs-CRP and NE, but not epinephrine. CONCLUSIONS: These results indicate that measurements of hs-CRP, ET-1 and NE may be useful in the identification of endothelial dysfunction and sympathetic activation in young patients with properly controlled essential arterial hypertension and without hyperlipidaemia.

Perfusion defects on real-time myocardial contrast echocardiography predict higher mortality in patients with end-stage renal disease - a 3-year follow-up.

AIM: The aim of this study was to assess the prognostic significance of myocardial contrast echocardiography (MCE) in patients with end-stage renal disease (ESRD) on a 3-year follow-up and to compare the value of MCE with demographic, clinical, and laboratory parameters. METHODS: Fifty-eight ESRD patients on regular dialysis were prospectively screened for coronary artery disease (CAD) using perfusion assessment on real-time MCE. We analyzed the following end points during the 3-year follow-up: death, cardiovascular complications, and combined end point, which consisted of adverse cardiac events mentioned above. All features were compared between the two groups with and without perfusion disturbances on MCE. RESULTS: No adverse events related to MCE administration have been observed. Twenty-seven (47%) patients with ESRD demonstrated perfusion defects on MCE. The patients with perfusion defects on MCE comparison with those without perfusion disturbances were older (p = 0.008) and had lower ejection fraction (EF) (p = 0.0001) and higher wall motion index (WMSI) (p = 0.0001). After the 3-year follow-up, the incidence of death (p = 0.00018), cardiovascular end points, revascularizations [both percutaneous coronary intervention (PCI) and coronary artery bypass grafts (CABG) p = 0.0016 and p = 0.004, respectively], and composite end point (p = 0.0015) was significantly higher in patients with perfusion defect on MCE. CONCLUSIONS: In patients with ESRD, MCE appears to be a safe and useful tool for risk stratification. MCE facilitates decision for coronary angiography.

Salivary Oxidative Stress Increases With the Progression of Chronic Heart Failure.

The aim of the study was to evaluate the rate of reactive oxygen species (ROS) production, antioxidant barrier, and oxidative damage in non-stimulated (NWS) and stimulated (SWS) saliva as well as plasma/erythrocytes of 50 patients with chronic heart failure (HF) divided into the two subgroups: NYHA II (33 patients) and NYHA III (17 patients). The activity of superoxide dismutase and catalase was statistically increased in NWS of HF patients as compared to healthy controls. The free radical formation, total oxidant status, level of uric acid, advanced glycation end products (AGE), advanced oxidation protein products and malondialdehyde was significantly elevated in NWS, SWS, and plasma of NYHA III patients as compared to NYHA II and controls. We were the first to demonstrate that with the progression of HF, disturbances of enzymatic and non-enzymatic antioxidant defense, and oxidative damage to proteins and lipids occur at both central (plasma/erythrocytes) and local (saliva) levels. In the study group, we also observed a decrease in saliva secretion, total salivary protein and salivary amylase activity compared to age- and gender-matched control group, which indicates secretory dysfunction of salivary glands in patients with HF. Salivary AGE may be a potential biomarker in differential diagnosis of HF.

Galectin-3 as the Prognostic Factor of Adverse Cardiovascular Events in Long-Term Follow up in Patients after Myocardial Infarction-A Pilot Study.

Galectin-3 (Gal-3) is a new independent risk factor in the development and severity of coronary artery disease (CAD). The aim of the study was to evaluate whether Gal-3 concentration has prognostic value and if it reflects the progression of atherosclerosis in carotid arteries in patients with CAD after acute myocardial infarction (AMI). The analysis included 110 patients who were hospitalized due to AMI, treated with primary coronary intervention (PCI) and further attended a follow-up visit, and 100 healthy volunteers. The Gal-3 concentration and carotid ultrasound were evaluated at baseline and on a follow-up visit. We found that the Gal-3 concentration in the group with hyperlipidemia decreased during the observation (10.7 vs. 7.9 ng/mL, p = 0.00003). Patients rehospitalized during follow up had higher concentration of Gal-3 in the acute phase of myocardial infarction (MI) (10.7 vs. 7.2 ng/mL, p = 0.02; 10.1 vs. 8.0 ng/mL, p = 0.002, respectively). In the group of patients who had none of the following endpoints: subsequent MI, PCI, coronary artery bypass grafting (CABG) or stroke, there was a decrease in Gal-3 concentration at the follow-up visit. Parameters affecting the frequency of a composite endpoint occurrence are: the presence of atheromatous plaque in the carotid artery (p = 0.017), Gal-3 (p = 0.004) and haemoglobin (p = 0.03) concentration. In multivariate analysis, only Gal-3 concentration higher than 9.2 ng/mL at discharge was associated with a nine-fold increase of risk of composite endpoint occurrence (p = 0.0005, OR = 9.47, 95% CI 2.60-34.45). A significant decrease in Gal-3 concentration was observed in the group of patients after AMI without the endpoint occurrence during observation.

Advance Care Planning in an Accountable Care Organization Is Associated with Increased Advanced Directive Documentation and Decreased Costs.

BACKGROUND: Advance care planning (ACP) documents patient wishes and increases awareness of palliative care options. OBJECTIVE: To study the association of outpatient ACP with advanced directive documentation, utilization, and costs of care. DESIGN: This was a case-control study of cases with ACP who died matched 1:1 with controls. We used 12 months of data pre-ACP/prematch and predeath. We compared rates of documentation with logit model regression and conducted a difference-in-difference analysis using generalized linear models for utilization and costs. SETTING/SUBJECTS: Medicare beneficiaries attributed to a large rural-suburban-small metro multisite accountable care organization from January 2013 to April 2016, with cross reference to ACP facilitator logs to find cases. MEASUREMENTS: The presence of advance directive forms was verified by chart review. Cost analysis included all utilization and costs billed to Medicare. RESULTS: We matched 325 cases and 325 controls (51.1% female and 48.9% male, mean age 81). 320/325 (98.5%) ACP versus 243/325 (74.8%) of controls had a Healthcare Power of Attorney (odds ratio [OR] 21.6, 95% CI 8.6-54.1) and 172/325(52.9%) ACP versus 145/325 (44.6%) controls had Practitioner Orders for Life Sustaining Treatment (OR 1.40, 95% CI 1.02-1.90) post-ACP/postmatch. Adjusted results showed ACP cases had fewer inpatient admissions (-0.37 admissions, 95% CI -0.66 to -0.08), and inpatient days (-3.66 days, 95% CI -6.23 to -1.09), with no differences in hospice, hospice days, skilled nursing facility use, home health use, 30-day readmissions, or emergency department visits. Adjusted costs were $9,500 lower in the ACP group (95% CI -$16,207 to -$2,793). CONCLUSIONS: ACP increases documentation and was associated with a reduction in overall costs driven primarily by a reduction in inpatient utilization. Our data set was limited by small numbers of minorities and cancer patients.

Prognostic significance of the admission plasma B-type natriuretic peptide measurement in patients with first ST-elevation myocardial infarction in comparison with C-reactive protein and TIMI risk score.

BACKGROUND: In ST-elevation myocardial infarction (STEMI) B-type natriuretic peptide (BNP) holds promise for risk stratification. Aim of this study was to assess prognostic value of plasma BNP measurement and to compare with other powerful prognostic markers -- TIMI Risk Score (TRS) and C-reactive protein (CRP) in patients with first STEMI treated with primary PCI (pPCI). METHODS: 86 patients, admitted within initial 12 h of the first STEMI. Admission plasma levels of BNP were measured by MEIA method. Serum levels of CRP were measured using immunoturbidimetric assays. Composite end point (CEP) was assessed after 7 months. RESULTS: Median plasma BNP value was higher in patients with CEP, compared with those without CEP (p<0.001). Patients with plasma BNP >99.2 pg/mL were at significantly higher risk for CEP (the highest sensitivity and specificity). CRP level >10.6 mg/dL was also associated with poor outcome. TRS has not influenced the occurrence of CEP. In the analysis of logistic regression the BNP value >99.2 pg/mL was the strongest predictor of CEP. ROC analysis identified BNP measurement as significant to estimate adverse outcome 0.950 in the prediction of CEP (95% Confidence interval=0.878-0.985). CONCLUSION: Admission plasma BNP concentrations provide incremental prognostic information in patients with first STEMI treated with pPCI.

[Suspected clopidogrel resistance associated with recurrent coronary stent thrombosis--a case report]. / Podejrzenie opornosci na klopidogrel u chorego z nawracajaca zakrzepica w stencie.

We describe a case of an 81-year-old man with acute ST-elevation myocardial infarction (STEMI), who received a loading dose of clopidogrel (300 mg) and aspirin (ASA) (300 mg) prior to primary coronary intervention of critical left anterior descending coronary artery stenosis. Three days later he developed recurrent acute STEMI due to the in-stent thrombosis and a second stent implantation was performed. The dose of clopidogrel (75 mg) remained unchanged, while the dose of ASA was increased from 75 mg to 150 mg. Three days later the patient had an other STEMI due to the in-stent thrombosis and additional stent implantation with IIb/IIIa blocker was performed. Clopidogrel resistance was suspected. Therefore, clopidogrel was replaced by ticlopidine, the dose of ASA was increased and low-molecular heparin was administered. Since then, the patient has been clinically stable. Our case indicates the existence of a subgroup of patients with combined clopidogrel and ASA resistance.

Deliberate Practice with Standardized Patient Actors and the Development of Formative Feedback for Advance Care Planning Facilitators.

OBJECTIVE: Multimodal curricular assessment after adding standardized patient (SP) actor-based simulation to an advance care planning (ACP) facilitator training course and development of a formative feedback tool. BACKGROUND: ACP represents a highly valued service requiring more and better trained facilitators. METHODS: Participants were primarily nurses and social workers in a large multisite health system. The course included a precourse video demonstration of ACP, traditional lectures, and four 30-minute simulations with SPs. Knowledge was tested with a multiple choice question (MCQ) test. In addition to standard postcourse/postsimulation evaluations, learners were surveyed pre/post/30-90 days delayed for self-perceived confidence. A linear mixed-effects model was used to analyze changes over time. Trained faculty rated performance in simulations with an observational mini-clinical examination (mini-CEX)-type rating form with a checklist, global competency, and global communication rating. Inter-rater reliability (IRR) was calculated on randomly selected paired ratings. RESULTS: Sixty-seven individuals consented to participate. MCQ scores improved from 83% ± 10% to 92% ± 8% (p < 0.001). Paired learner surveys of self-confidence across six domains were available for 65 pre, 65 post, and 40 delayed with a mean positive change on a 0 to 10 point scale from pre-post (2.32 ± 1.65; p < 0.001) and predelayed (2.34 ± 1.96; p < 0.001) time frames. For the faculty observation ratings of simulation performance, the average raw agreement for critical actions was 82% and IRR was 0.71. CONCLUSIONS: Learner feedback and self-assessment suggest that actor-based simulation contributed to improved confidence in conducting ACP. The mini-CEX observation form is adequate for formative feedback, with further testing needed to make judgments of competence.