Asthma-chronic obstructive pulmonary disease overlap and cost-related medication non-adherence among older adults in the United States.

BACKGROUND: Cost-related medication non-adherence (CRN) can negatively impact health outcomes in older adults with asthma and chronic obstructive pulmonary disease (COPD) overlap (ACO) by reducing access and adherence to essential medications. The objective of this study is to examine the association of ACO to any CRN and specific forms of CRN among a nationally representative sample of older (age ≥ 65 years) adults. METHODS: We adopted a cross-sectional study design using data from pooled cross-sectional Medicare Current Beneficiary Surveys (MCBS) (2006-2013) and linked fee-for-service Medicare claims. Unadjusted and adjusted logistic regressions that accounted for the complex survey design examined the association of ACO to any CRN and specific forms of CRN. RESULTS: Among older adults with ACO, 16% reported any CRN. The most common form of CRN was "failing to get prescription". As compared to older adults with no asthma and no COPD, those with ACO were more likely to report any CRN (adjusted odds ratios [AOR] = 1.50, 95%CI = [1.14, 1.96]) and all forms of CRN. However, when the number of unique medications was added to the model, there were no statistically significant differences in CRN between the two groups. CONCLUSIONS: Older adults with ACO represent a vulnerable population with increased risk for CRN. Multiple factors can contribute to CRN including: a higher number of prescribed medications, multiple co-morbidities, and cost of therapies. Medication comprehensive review interventions have the potential of reducing the risk of CRN among the older Medicare beneficiaries with ACO.

Idiopathic bilateral diaphragmatic dysfunction as a cause of dyspnea.

Diaphragmatic paralysis is an unusual and often underrecognized cause of dyspnea. We present a case of bilateral diaphragmatic paralysis with no identifiable etiology. Our patient is a 73-year-old female with a history of smoking who presented with dyspnea and orthopnea. She was treated for obstructive lung disease with no improvement in dyspnea despite adequate therapy. She had pulmonary function tests (PFTs) that revealed marked decrease in vital capacity and was unable to perform lung volume maneuvers supine due to marked dyspnea. The maximal inspiratory pressure was 37 in the upright position and decreased to 27 in the supine position. She was given a presumptive diagnosis of idiopathic bilateral diaphragmatic dysfunction. Given the history, physical exam, and PFT findings, we felt that the patient did not need further invasive testing. The patient was treated with noninvasive mechanical ventilation due to hypercapnia and her symptoms improved.

Intensified tuberculosis case finding among HIV-infected persons using a WHO symptom screen and Xpert(®) MTB/RIF.

SETTING: Human immunodeficiency virus (HIV) clinic in Addis Ababa, Ethiopia. The World Health Organization (WHO) recommends active tuberculosis (TB) case-finding among people living with HIV (PLHIV) in high-burden settings. OBJECTIVE: To evaluate the effectiveness of combining a WHO-recommended symptom screen and the Xpert(®) MTB/RIF test to enhance TB case finding. DESIGN: In this cross-sectional study, PLHIV were screened for TB using a WHO-recommended symptom-based algorithm (cough, fever, night sweats, weight loss). Those with a positive symptom screen (⩾1 symptom) underwent diagnostic testing with smear microscopy, culture, and Xpert. RESULTS: Of 828 PLHIV (89% on antiretroviral therapy), 321 (39%) had a positive symptom screen. In multivariate analysis, an unscheduled clinic visit (aOR 3.78, 95%CI 2.69-5.32), CD4 count <100 cells/µl (aOR 2.62, 95%CI 1.23-5.59) and previous history of TB (aOR 1.62, 95%CI 1.12-2.31) were predictors of a positive symptom screen. Among those with a positive symptom screen, 6% had active pulmonary TB. Smear microscopy sensitivity for TB was poor (30%) compared to culture and Xpert. CONCLUSIONS: A positive symptom screen was common among PLHIV, creating a substantial laboratory burden. Smear microscopy had poor sensitivity for active TB disease. Given the high rate of positive symptom screen, substantial additional resources are needed to implement intensified TB case finding among PLHIV in high-burden areas.

Laser technology and applications in gynaecology.

The term 'laser' is an acronym for Light Amplification by Stimulated Emission of Radiation. Lasers are commonly described by the emitted wavelength, which determines the colour of the light, as well as the active lasing medium. Currently, over 40 types of lasers have been developed with a wide range of both industrial and medical uses. Gas and solid-state lasers are frequently used in surgical applications, with CO2 and Ar being the most common examples of gas lasers, and the Nd:YAG and KTP:YAG being the most common examples of solid-state lasers. At present, it appears that the CO2, Nd:YAG, and KTP lasers provide alternative methods for achieving similar results, as opposed to superior results, when compared with traditional endoscopic techniques, such as cold-cutting monopolar and bipolar energy. This review focuses on the physics, tissue interaction, safety and applications of commonly used lasers in gynaecological surgery.

Complications of endovenous lasers.

Endovenous laser ablation (EVLA) and radiofrequencey ablation have become the procedures of choice for the treatment of superficial venous insufficiency. Their minimally invasive technique and safety profile when compared with operative saphenectomy have led to this change. As EVLA has replaced saphenectomy as the procedure of choice, the distribution of complications has changed. We evaluated the most common and most devastating complications in the literature including burns, nerve injury, arterio-venous fistula (AVF), endothermal heat-induced thrombosis and deep venous thrombosis. The following review will discuss the most frequently encountered complications of treatment of superficial venous insufficiency using EVLA. The majority of the complications described can be avoided with the use of good surgical technique and appropriate duplex ultrasound guidance. Overall, EVLA has an excellent safety profile and should be considered among the first line for treatment of superficial venous reflux.

Percutaneous drainage of aortic aneurysm sac abscesses following endovascular aneurysm repair.

PURPOSE: To report preliminary experiences with the treatment of aortic aneurysm sac abscesses following prior endovascular aortic aneurysm repair (EVAR) using computerized tomography (CT)-guided percutaneous drainage. CASE REPORTS: Three patients aged 73 to 78 years with aortic aneurysm sac infections following prior EVAR, 2 of which were associated with aortoduodenal fistula, underwent CT-guided percutaneous drainage and catheter placement. One patient had complete resolution of the aortic aneurysm sac abscess following percutaneous drainage; 1 patient was stabilized to eventual extraanatomic bypass, graft explantation, and fistula repair; and 1 patient was temporized to debridement and fistula repair with endograft preservation. CONCLUSION: CT-guided percutaneous drainage may be a helpful therapy in selected patients for the treatment of aortic aneurysm sac infections following EVAR.

Experience and technique for the endovascular management of iatrogenic subclavian artery injury.

BACKGROUND: Inadvertent subclavian artery catheterization during attempted central venous access is a well-known complication. Historically, these patients are managed with an open operative approach and repair under direct vision via an infraclavicular and/or supraclavicular incision. We describe our experience and technique for endovascular management of these injuries. METHODS: Twenty patients were identified with inadvertent iatrogenic subclavian artery cannulation. All cases were managed via an endovascular technique under local anesthesia. After correcting any coagulopathy, a 4-French glide catheter was percutaneously inserted into the ipsilateral brachial artery and placed in the proximal subclavian artery. Following an arteriogram and localization of the subclavian arterial insertion site, the subclavian catheter was removed and bimanual compression was performed on both sides of the clavicle around the puncture site for 20 min. A second angiogram was performed, and if there was any extravasation, pressure was held for an additional 20 min. If hemostasis was still not obtained, a stent graft was placed via the brachial access site to repair the arterial defect and control the bleeding. RESULTS: Two of the 20 patients required a stent graft for continued bleeding after compression. Both patients were well excluded after endovascular graft placement. Hemostasis was successfully obtained with bimanual compression over the puncture site in the remaining 18 patients. There were no resultant complications at either the subclavian or the brachial puncture site. CONCLUSION: This minimally invasive endovascular approach to iatrogenic subclavian artery injury is a safe alternative to blind removal with manual compression or direct open repair.

Multidimensional characterization of carotid artery stenosis using CT imaging: a comparison with ultrasound grading and peak flow measurement.

PURPOSE: Clinical decision making for carotid surgery depends largely upon stenosis grade. While digital subtraction angiography remains the gold standard for stenosis grading, many physicians use less invasive modalities. The purpose of this study was to compare the results of multidimensional Computed tomography (CTA) with ultrasound (US) grading and peak flow velocity (PSV). METHODS: 37 stenosed carotid arteries were studied retrospectively in 36 consecutive patients. US grading and PSV were compared to multidimensional CTA analysis (diameter, area and volumetric measurements), performed by a medical software company. Calculations of stenosis percentage on CTA were made using the NASCET and ECST methodology. Diameter measurements were also performed by a neuroradiologist. RESULTS: All CTA diameter, area and volume measurements had only modest correlation with PSV (r<0.5) and ultrasound grading (p<0.5). There was concordant classification of stenosis grades in only 40-60% of cases. CTA diameter, area and volume measurements had good correlation (0.69

Regional nerve block allows for optimization of planning in the creation of arteriovenous access for hemodialysis by improving superficial venous dilatation.

Durable vascular access for hemodialysis remains a critical issue in end-stage renal disease patients. Creation of an autogenous arteriovenous (AV) fistula in the most distal location of the nondominant extremity is the preferred technique and provides superior patency over an AV graft. Others have shown that regional anesthesia in the form of axillary block results in the dilatation of the native veins and allows for their increased utilization in creating AV fistulae. We report on 26 patients undergoing creation of a vascular access for hemodialysis. Regional anesthesia consisting of axillary nerve block was used in all cases. All surgical plans with regard to the site and type of access were made based on the physical exam and ultrasound vein measurements taken prior to surgery. On the day of surgery patients were reevaluated with venous ultrasound using tourniquet before and after administration of the regional block. The previously determined operative plan either remained unchanged or was modified depending on the venous dilatation noted after administration of regional block. Among 26 patients, average vein diameter increased from 0.29 +/- 0.12 cm to 0.34 +/- 0.11 cm (P = 0.008). Twenty-one of 26 patients had no modification in operative plan (group 1). Five had some modification of the original operative plan (group 2): AV graft to a brachial vein transposition (n = 2), AV graft to a Cimino fistula (n = 2), and brachiocephalic to a Cimino (n = 1). The average follow-up for all patients was 82.6 +/- 75.6 days and did not differ between the groups. There was one failure in a patient from group 1, and there was no significant difference in the patency rate between study groups (P = 0.29). Following regional nerve block, operative plans in patients undergoing AV access surgery were modified in 29.4% of patients undergoing creation of an AV access for hemodialysis; either from graft to fistula creation or from the proximal to more distal fistula site. The routine use of regional anesthesia as well as intraoperative ultrasound during AV access surgery can lead to improved site selection and increased opportunity for AV fistula creation.

Initial successful management of type I endoleak after endovascular aortic aneurysm repair with n-butyl cyanoacrylate adhesive.

OBJECTIVE: Transcatheter embolization with coils and other agents has been described as a treatment method for type II endoleak after endovascular aortic aneurysm repair (EVAR). Type I endoleak has not been treated commonly with such therapies, although most investigators believe they warrant definitive intervention. The liquid adhesive n-butyl 2-cyanoacrylate (n-BCA) is often used to treat congenital arteriovenous malformations. The objective of this study is to report our initial experience in treating type I endoleak with n-BCA and with a variety of other interventions. METHODS: A retrospective review was performed of 270 patients who underwent EVAR at our institution between January 1994 and December 2002. Of these, 24 patients had type I endoleak (8.9%), diagnosed either intraoperatively (n = 13, 52%) or during follow-up (n = 12, 48%). Among these 24 patients, 17 had proximal leaks and the remaining 8 patients had distal leaks. These cases form the focus of this study. RESULTS: Twenty-two leaks required endovascular intervention, with the following success rate: n-BCA, 12 of 13 cases (92.3%); extender cuffs, 4 of 5 cases (80%); coils with or without thrombin, 3 of 4 cases (75%). In one patient with persistent endoleak despite attempted endovascular intervention the device ultimately was surgically explanted, and the patient did well. Of six patients with endoleak initially managed expectantly, two eventually underwent attempts at definitive intervention, both with n-BCA. Three sealed spontaneously before definitive intervention could be performed; and in one 97-year-old patient who refused intervention, the aneurysm subsequently ruptured and the patient died. In total, 13 patients with type I endoleak underwent n-BCA transcatheter embolotherapy. No serious complications were directly related to this therapy. Colon ischemia developed in one patient, and was believed to be a result of thromboembolism during wire and catheter manipulation rather than n-BCA treatment. Twelve of these 13 leaks remain sealed at mean follow-up of 5.9 months (range, 0-19 months). CONCLUSION: Our initial use of n-BCA occlusion suggests that it may be an effective and safe method of treatment of type I endoleak after EVAR. In particular, n-BCA embolotherapy may be especially useful in treating type I endoleak not amenable to placement of extender cuffs. Larger case series and longer follow-up are needed before this treatment is more broadly recommended. Type I endoleak after EVAR can be treated successfully with a variety of endovascular methods, and surgical explantation is rarely required.

Natural autoantibodies to TCR public idiotopes: potential roles in immunomodulation.

Autoantibodies directed against variable domain epitopes of the alpha/beta T cell receptor (TCR) occur in sera of man, mouse and other vertebrates. Here, we focus upon autoantibodies expressed in human rheumatoid arthritis (RA) and systemic erythematosus (SLE) with parallel studies involving collagen induced arthritis (CIA) in mice transgenic for human HLA-DR conferring resistance or susceptibility to autoimmune disease. We report specificity characterization of polyclonal and monoclonal IgM and IgG autoantibodies from SLE and for IgM monoclonal autoantibodies of RA patients. The data suggests that autoantibodies directed against "public" idiotopes present in the first complementarity determining region (CDR1) and the third framework (FR3) of the Vbeta gene products are generated in response to over-production of autodestructive T cells bearing particular Vbeta gene products and function to modulate (downregulate) the expression of these T cells. Since antibodies of these specificities are present in polyclonal IgG immunoglobulin (IVIG) preparations used for therapeutic purposes, the immunomodulatory effects of antibodies directed against TCR variable domains may account, at least in part, for the efficacy of IVIG preparations in therapy of autoimmune diseases and in the prevention of graft versus host reactions.

Endovascular abdominal aortic aneurysm (AAA) repair since the FDA approval. Are we going too far?

BACKGROUND: Since the FDA approval of endovascular devices for abdominal aortic aneurysm (AAA) repair, clinicians have been relaxing the strict inclusion criteria of the clinical trials. We have reviewed our experience during and after the clinical trials to examine changes in patient selection, technical aspects of the procedure, and outcome. METHODS: A review of a prospectively compiled database of all endovascular AAA repairs performed at our institution was performed. RESULTS: Endovascular AAA repair was attempted in 130 patients: 46 (35.4%) as a part of clinical trials (Group I), and 84 (64.6%) since the FDA approval of the devices (Group II). Significant differences in patient selection included: a higher proportion of short (<15 mm) proximal necks in Group II (28.6 vs 0.0%, p<0.001), and a higher proportion of iliac occlusive disease in Group II (48.8 vs 15.4%, p=0.001). Additional trends suggested that Group II AAA's were more complex, including increased proximal neck angulation, increased proximal calcification, increased presence of proximal thrombus, and increased iliac tortuosity. Significant differences in technical aspects of the procedure included increased usage of iliac angioplasty (46.4 vs 13.3%, p<0.001), iliac stenting (31 vs 8.9%, p<0.01), and conduit access to the external iliac artery (10.7 vs 0%, p=0.03) in Group II. Analysis of outcome revealed a decreased incidence of the following in Group II cases: conversions to open repair (2.4 vs 10.9%), lower extremity ischemia (3.6 vs 13.0%), and graft limb occlusion (2.4 vs 8.7%). Other major perioperative complications did not differ significantly between the 2 groups. However, although the overall rate of any endoleak noted in the postoperative course was decreased in Group II cases (26.2 vs 32.6%), the incidence of proximal or distal attachment site leaks has increased (11.9 vs 4.3%, p=0.14). Although this comparison did not reach statistical significance, the magnitude of the increase is concerning. CONCLUSIONS: Although we have been able to offer endovascular AAA repair to a larger number of patients since FDA approval, endovascular management of increasingly complex proximal necks and increased iliac artery disease appears to have increased the incidence of attachment site endoleaks. Although many of these leaks have been successfully managed with adjunctive endovascular procedures, their increasing incidence is worrisome and suggests that we may need to re-evaluate current inclusion criteria for using this technology. Although difficult access issues have been handled with adjunctive procedures, the presence of a short, angulated proximal neck may be difficult to overcome, and may not be well suited for endovascular repair with the currently available devices.

Abdominal aortic aneurysms and thoracic aortic atheromas.

BACKGROUND: Abdominal aortic aneurysm (AAA) is associated with atherosclerosis elsewhere. Thoracic aortic atheromas (ATHs) seen on transesophageal echocardiography (TEE) are an important cause of stroke and peripheral embolization. The purposes of this study were to determine whether an association exists between AAA and ATHs and to assess the importance of screening patients with ATHs for AAA. METHODS: For the retrospective analysis, 109 patients with AAA and 109 matched controls were compared for the prevalence of ATHs on TEE and for historical variables. For the prospective analysis, screening for AAA on ultrasonography was performed in 364 patients at the time of TEE. RESULTS: Results of the retrospective analysis showed that ATHs were present in 52% of patients with AAA and in 25% of controls (odds ratio [OR] = 3.3; P =.00003). There was a significantly higher prevalence of hypertension, myocardial infarction, heart failure, smoking, and carotid or peripheral arterial disease in patients with AAA. However, only ATHs were independently associated with AAA on multivariate analysis (P =.001). Results of the prospective analysis showed that screening at the time of TEE in 364 patients revealed AAA in 13.9% of those with ATHs and in 1.4% of those without ATHs (P <.0001; OR = 11.4). CONCLUSIONS: (1) There is a strong, highly significant association between abdominal aneurysm and thoracic atheromas. (2) Patients with AAA may be at high risk for stroke because of the concomitance of thoracic aortic atheromas. (3) The high prevalence of abdominal aneurysm in patients with thoracic atheromas suggests that screening for abdominal aneurysm should be carried out in all patients with thoracic atheromas identified by TEE.

Carotid endarterectomy in patients 55 years of age and younger.

Prior studies have suggested that young patients may be more prone to recurrent disease after carotid endarterectomy (CEA). The goal of this study was to review a series of CEAs performed on younger patients (< or = 55 years) and to determine if these patients are more likely to develop recurrent stenosis. A review was conducted of CEAs performed from 1985 through 1994. Analysis was performed on a study group of 94 young patients who underwent 109 CEAs during this time. A control group of 222 patients older than 55 years who underwent 256 CEAs during the years 1991 through 1993 was selected for comparison. During a mean of nearly 4 years of follow-up, younger patients were significantly more likely to experience a late failure of CEA, including total occlusion of the operated artery, or recurrent stenosis requiring redo surgery. Careful patient evaluation is important in choosing younger patients who require CEA. Implications of these data include mandating careful noninvasive follow-up examinations for younger patients undergoing CEA.

Infrarenal abdominal aortic aneurysms at multi-detector row CT angiography: intravascular enhancement without a timing acquisition.

In 70 patients referred for evaluation of aortoiliac aneurysm disease, multi-detector row computed tomography was performed with a uniform 25-second delay from the initiation of intravenous administration of a 150-mL bolus of contrast material at 4 mL/sec. In all patients, adequate enhancement (>200 HU) of the aorta and intense enhancement of iliofemoral runoff was achieved without venous contamination.

Long-term follow-up of saphenous vein, internal jugular vein, and knitted Dacron patches for carotid artery endarterectomy.

To determine whether choice of material used for patch closure following carotid artery endarterectomy (CAE) influences rates of early or late restenosis, stroke, and death, 274 consecutive CAEs were retrospectively reviewed. Saphenous vein (SV) was used in 159 (58.0%) procedures; everted, double-thickness jugular vein (JV) was used in 25 (9.1%); and knitted Dacron (KD) was used in 90 (32.9%). Primary closure was not used in this series. There were four perioperative strokes: two (1.3%) in SV, one (4%) in JV, and one (1.1%) in KD (NS). Follow-up was obtained on 263 (96%) operated arteries (mean 41.5 months). Duplex scan results were available for 236 (89.7%) of these arteries (mean follow-up time 33.7 months). There were three (2%) late strokes in SV and two (2.2%) in KD (NS). In long-term follow-up, one patient (0.7%) in SV and two (2.4%) in KD developed > 80% stenosis (NS). One patient (0.7%) in SV, one (5.3%) in JV, and one (1.2%) in KD had total occlusion of the operated vessel (NS). Three procedures (2.2%) in SV, 1 (5.3%) in JV, and 7 (8.5%) in KD demonstrated moderate stenosis (50-79%) (NS). Three-year follow-up shows that choice of patch material does not affect early or late stroke rate, stroke-related death rate, rate of high-grade (> 80%) restenosis, or rate of total occlusion. There is a higher incidence of moderate stenosis in KD. Although our results and a review of the literature do not indicate that these patients are at increased risk for symptoms or progression of stenosis, they should be followed by duplex scanning to ensure that this is the case.