External Cardioversion-Defibrillation with Pushing Down on the Chest Wall to Increase the Success Rate in Obese Patients.

BACKGROUND The energy delivered by a defibrillator is expressed in joules (J). However, current is what actually defibrillates the heart and is related to the voltage-to-impedance ratio. With the same energy, the lower the transthoracic impedance, the higher the current delivered. In obese patients, pushing the chest wall toward the heart during electric shock can result in an improved outcome. CASE REPORT We report the cases of 3 obese patients with previously failed cardioversion/defibrillation who had an eventual shock success. (1) A 17-year-old girl failed multiple defibrillation efforts for her recurrent ventricular fibrillation. After ECMO, with the physician pushing down the chest wall, a 200-J defibrillation converted her VF. (2) A 63-year-old man with recurrent atrial fibrillation (AF) had an unsuccessful 150-J shock followed by a successful 200-J cardioversion. His AF recurred. After amiodarone bolus, a 200-J shock converted it to sinus. Another recurrent AF failed 150-J cardioversion. With chest pushing down, a 150-J cardioversion was successful. (3) A 65-year-old man underwent elective cardioversion for AF. A 200-J shock was unsuccessful. A 200-J shock with pressure on the chest successfully converted it. CONCLUSIONS We performed successful electrical cardioversion/defibrillation with this "pushing down the chest while shocking" method. Many clinicians are still unaware of this method, especially in obese patients. With the increasing prevalence of obesity, it is urgent to perform a randomized study to confirm the efficacy and safety of this method, and integrate it into advanced cardiac life support protocols.

Using value-based analysis to influence outcomes in complex surgical systems.

BACKGROUND: Value-based analysis (VBA) is a management strategy used to determine changes in value (quality/cost) when a usual practice (UP) is replaced by a best practice (BP). Previously validated in clinical initiatives, its usefulness in complex systems is unknown. To answer this question, we used VBA to correct deficiencies in cardiac surgery at Memorial Healthcare System. STUDY DESIGN: Cardiac surgery is a complex surgical system that lends itself to VBA because outcomes metrics provided by the Society of Thoracic Surgeons provide an estimate of quality; cost is available from Centers for Medicare and Medicaid Services and other contemporary sources; the UP can be determined; and the best practice can be established. RESULTS: Analysis of the UP at Memorial Healthcare System revealed considerable deficiencies in selection of patients for surgery; the surgery itself, including choice of procedure and outcomes; after care; follow-up; and control of expenditures. To correct these deficiencies, each UP was replaced with a BP. Changes included replacement of most of the cardiac surgeons; conversion to an employed physician model; restructuring of a heart surgery unit; recruitment of cardiac anesthesiologists; introduction of an interactive educational program; eliminating unsafe practices; and reducing cost. CONCLUSIONS: There was a significant (p < 0.01) reduction in readmissions, complications, and mortality between 2009 and 2013. Memorial Healthcare System was only 1 of 17 (1.7%) database participants (n = 1,009) to achieve a Society of Thoracic Surgeons 3-star rating in all 3 measured categories. Despite substantial improvements in quality, the cost per case and the length of stay declined. These changes created a savings opportunity of $14 million, with actual savings of $10.4 million. These findings suggest that VBA can be a powerful tool to enhance value (quality/cost) in a complex surgical system.

Epithelial cell proliferation contributes to airway remodeling in severe asthma.

RATIONALE: Despite long-term therapy with corticosteroids, patients with severe asthma develop irreversible airway obstruction. OBJECTIVES: To evaluate if there are structural and functional differences in the airway epithelium in severe asthma associated with airway remodeling. METHODS: In bronchial biopsies from 21 normal subjects, 11 subjects with chronic bronchitis, 9 subjects with mild asthma, and 31 subjects with severe asthma, we evaluated epithelial cell morphology: epithelial thickness, lamina reticularis (LR) thickness, and epithelial desquamation. Levels of retinoblastoma protein (Rb), Ki67, and Bcl-2 were measured, reflecting cellular proliferation and death. Terminal deoxynucleotidyl-mediated dUTP nick end labeling (TUNEL) was used to study cellular apoptosis. MEASUREMENTS AND MAIN RESULTS: Airway epithelial and LR thickness was greater in subjects with severe asthma compared with those with mild asthma, normal subjects, and diseased control subjects (p=0.009 and 0.033, respectively). There was no significant difference in epithelial desquamation between groups. Active, hypophosphorylated Rb expression was decreased (p=0.002) and Ki67 was increased (p<0.01) in the epithelium of subjects with severe asthma as compared with normal subjects, indicating increased cellular proliferation. Bcl-2 expression was decreased (p<0.001), indicating decreased cell death suppression. There was a greater level of apoptotic activity in the airway biopsy in subjects with severe asthma as compared with the normal subjects using the TUNEL assay (p=0.002), suggesting increased cell death. CONCLUSIONS: In subjects with severe asthma, as compared with subjects with mild asthma, normal subjects, and diseased control subjects, we found novel evidence of increased cellular proliferation in the airway contributing to a thickened epithelium and LR. These changes may contribute to the progressive decline in lung function and airway remodeling in patients with severe asthma.

The role of viral respiratory infections in the pathogenesis and exacerbation of asthma.

Respiratory viral infections are implicated in both the pathogenesis and exacerbation of asthma. Infections with respiratory syncytial virus and parainfluenza virus are the major cause of wheezing-related respiratory infections early in life. Infections in early childhood affect the immune system and modify the risk for subsequent development of allergies and asthma. Later in life, rhinovirus and influenza are implicated frequently in the exacerbation of asthma. The management of respiratory viral infections includes adequate prophylaxis and treatment of acute infections. Insights into the mechanism of viral respiratory tract infections will provide therapeutic targets for treatment and possibly the prevention of virus-induced asthma.