A case report on umbilical artery catheter embolization in a neonate, and its surgical management.

Umbilical arterial and venous catheters are used widely in management of critically ill neonates. Being delicate, they can get inadvertently damaged by needles, scissors, or tight purse-string sutures during insertion and removal. Umbilical artery catheter embolization is a rare and dreaded complication, with less than 15 cases reported to date. We describe a term neonate, in whom a 3.5-Fr umbilical artery catheter, accidentally broken and dislodged, was surgically retrieved through right common iliac arteriotomy, safely and completely. Direct surgical retrieval of umbilical catheters while avoiding attempts at local exploration maybe considered a first line in management, particularly if endovascular facilities are unavailable or inaccessible.

Implementation of an Early Palliative Care Referral Program in Lung Cancer: A Quality Improvement Project at the Tata Memorial Hospital, Mumbai, India.

OBJECTIVES: Access to early palliative care (EPC) for all patients with metastatic lung cancer is yet to be achieved in spite of recommendations. This quality improvement (QI) project was initialized to improve the rates of such referrals from the thoracic oncology clinic for all new outpatients in a premier cancer center in India. MATERIALS AND METHODS: Change in the proportion of patients receiving referrals for EPC during and after intervention (April-May 2018), compared to baseline (January-March 2018) were explored. Interventions included understanding of the process flow, identification of key drivers, and root cause analysis which identified the gaps as lack of documentation for EPC. Teaching and encouraging staff at the clinic to incorporate referrals into all initial visits for patients with metastatic lung cancer were incorporated. RESULTS: The bundle of QI interventions increased referrals from an average of 50% to 75%, mean difference = 12.64 (standard deviation = 10.13) (95% confidence interval = 22.01-3.29), P = 0.016 (two-tailed) on paired sample test. CONCLUSION: Improved referral rates for EPC in a multidisciplinary cancer clinic is possible with a QI project. This project also identifies the importance of data documentation and patient information processes that can be targeted for improvement.

The Hidden Epidemic of Firearm Injury: Increasing Firearm Injury Rates During 2001-2013.

Investigating firearm injury trends over the past decade, we examined temporal trends overall and according to race/ethnicity and intent in fatal and nonfatal firearm injuries (FFIs and NFIs) in United States during 2001-2013. Counts of FFIs and estimated counts of NFIs were obtained from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System. Poisson regression was used to analyze overall and subgroup temporal trends and to estimate annual change per 100,000 persons (change). Total firearm injuries (n = 1,328,109) increased annually by 0.36 (Ptrend < 0.0001). FFIs remained constant (change = 0.02; Ptrend = 0.22) while NFIs increased (change = 0.35; Ptrend < 0.0001). Homicide FFIs declined (change = -0.05; Ptrend < 0.0001) while homicide NFIs increased (change = 0.43; Ptrend < 0.0001). Suicide FFIs increased (change = 0.07; Ptrend < 0.0001) while unintentional FFIs and NFIs declined (changes = -0.01 and -0.09, respectively; Ptrend < 0.0001 and 0.005). Among whites, FFIs (change = 0.15; Ptrend < 0.0001) and NFIs (change = 0.13; Ptrend < 0.0001) increased; among blacks, FFIs declined (change = -0.20; Ptrend < 0.0001). Among Hispanics, FFIs declined (change = -0.28; Ptrend < 0.0001) while NFIs increased (change = 0.55; Ptrend = 0.014). The endemic firearm-related injury rates during the first decade of the 21st century mask a shift from firearm deaths towards a rapid rise in nonfatal injuries.

Resting ST amplitude: prognosis and normal values in an ambulatory clinical population.

BACKGROUND: There is limited data describing ST segment amplitude in apparently healthy, asymptomatic populations. We analyzed ST amplitude in the standard resting electrocardiogram (ECG) in a large, multiethnic, stable, clinical population. METHODS: We evaluated computerized ST amplitude measurements from the resting ECGs of 29,281 ambulatory outpatients collected between 1987 and 1999 at the Palo Alto, VA. With the PR interval as the isoelectric line, both elevation criteria (≥0.1 mV, ≥0.15 mV, and ≥0.2 mV) and depression criteria (≤-0.05 mV or ≤-0.1 mV), were applied. Cox-Hazard survival analysis techniques were used to demonstrate in which leads ST amplitude displacement was associated with cardiovascular (CV) death. To create a cohort without ECG patterns clearly associated with disease, we excluded ECGs with inverted T waves, wide QRS, or diagnostic Q waves and coded the remaining "normal" ECGs for ST elevation and depression to determine a normal range. RESULTS: The only ST amplitudes that were significantly and independently associated with time to CV death when adjusted for age, gender, and ethnicity were ST depression in all of the lateral leads (I, V4 -V6 ). When isolated to the inferior leads, (II and AVF), no ST amplitude criteria were associated with CV death. Among the "normal ECG" subgroup the precordial leads exhibited the greatest median ST amplitudes and the most significant differences between the leads, genders and ethnicities. CONCLUSIONS: Significant differences in ST amplitude were present in the precordial leads according to gender and ethnicity. This was particularly apparent when amplitude threshold were set for comparisons. Our findings provide the normal range for ST amplitude that when exceeded, should raise clinical concern.

Spectrum of ST amplitude: athletes and an ambulatory clinical population.

BACKGROUND AND PURPOSE: To augment data guiding thresholds for myocardial ischemia and cardiac risk, we studied resting ST amplitude in ambulatory patients and collegiate athletes. METHODS: We analyzed 4041 ECGs from ambulatory visits at the Veterans Affairs in Palo Alto, California from 1997 to 1999 and 1114 screening ECGs from Stanford University athletes in 2007-2008. Using the PR interval as the isoelectric line and >95µV and<-45µV (visually equivalent to 1mm and 0.5mm) to define ST elevation and depression, ST amplitude was measured at QRS-end. RESULTS: ST elevation was most prevalent in males, African Americans, and athletes (87% of male athletes in anterior leads). ST depression was rare in athletes and, among patients, associated with time to cardiovascular death in lateral leads (age-adjusted HR of 1.9, p<0.001). CONCLUSIONS: ST amplitude differs by gender, age, race, and athletic status, which should be considered when developing guidelines for ECG interpretation.

Cardiopulmonary and noninvasive hemodynamic responses to exercise predict outcomes in heart failure.

BACKGROUND: An impaired cardiac output response to exercise is a hallmark of chronic heart failure (HF). We determined the extent to which noninvasive estimates of cardiac hemodynamics during exercise in combination with cardiopulmonary exercise test (CPX) responses improved the estimation of risk for adverse events in patients with HF. METHODS AND RESULTS: CPX and impedance cardiography were performed in 639 consecutive patients (mean age 48 ± 14 years), evaluated for HF. Clinical, hemodynamic, and CPX variables were acquired at baseline and subjects were followed for a mean of 460 ± 332 days. Patients were followed for the composite outcome of cardiac-related death, hospitalization for worsening HF, cardiac transplantation, and left ventricular assist device implantation. Cox proportional hazards analyses including clinical, noninvasive hemodynamic, and CPX variables were performed to determine their association with the composite endpoint. There were 113 events. Among CPX variables, peak oxygen uptake (VO(2)) and the minute ventilation (VE)/carbon dioxide production (VCO(2)) slope were significant predictors of risk for adverse events (age-adjusted hazard ratio [HR] 1.08, 95% confidence interval [CI] 1.05-1.11 for both; P < .001). Among hemodynamic variables, peak cardiac index was the strongest predictor of risk (HR 1.08, 95% CI 1.0-1.16; P = .01). In a multivariate analysis including CPX and noninvasively determined hemodynamic variables, the most powerful predictive model included the combination of peak VO(2), peak cardiac index, and the VE/VCO(2) slope, with each contributing significantly and independently to predicting risk; an abnormal response for all 3 yielded an HR of 5.1 (P < .001). CONCLUSIONS: These findings suggest that noninvasive indices of cardiac hemodynamics complement established CPX measures in quantifying risk in patients with HF.

Natural history of early repolarization in the inferior leads.

AIMS: Though early repolarization (ER) in the inferior leads has been associated with increased cardiovascular risk, its natural history is uncertain. We aimed to study the serial electrocardiographic behavior of inferior ER and understand factors associated with that behavior. METHODS: We selected electrocardiograms (ECGs) from patients with the greatest amplitude of ER in AVF from ECGs of 29,281 ambulatory patients recorded between 1987 and 1999 at the Palo Alto Veterans Affairs Hospital. Starting from the highest amplitude, we reviewed the ECGs and medical records from the first 85%. From this convenience sample, 36 were excluded for abnormal patterns similar to ER. The remaining 257 patients were searched for another ECG at least 5 months later, of whom, 136 satisfied this criteria. These ECGs were paired for comparison and coded by four interpreters. RESULTS: The average time between the first and second ECGs was 10 years. Of the 136 subjects, 47% retained ER while 53% no longer fulfilled the amplitude criteria. While no significant differences were found in initial heart rate (HR) or time interval between ECGs, those who lost the ER pattern had a greater difference in HR between the ECGs. There was no significant difference in the incidence of cardiovascular events or deaths. CONCLUSIONS: In conclusion, the ECG pattern of ER was lost over 10 years in over half of the cohort. The loss of ER was partially explained by changes in HR, but not higher incidence of cardiovascular events or death, suggesting the entity is a benign finding.

Natural history of the electrocardiographic pattern of early repolarization in ambulatory patients.

Although it is known that the electrocardiographic pattern of early repolarization (ER) occurs most commonly in healthy young bradycardic men, its natural history is uncertain. We considered initial electrocardiograms (ECGs) at rest from 29,281 ambulatory patients recorded from 1987 through 1999 at Veterans Affairs Palo Alto Hospital. With PR interval as the isoelectric line and amplitude criterion as >0.1 mV ER was identified when any of the following fulfilled the amplitude criterion: ST-segment elevation at the end of the QRS duration, J waves as an upward deflection, and slurs as delay on the R wave downstroke. The first 250 ECGs with the greatest ER increase were selected and the database was searched for an ECG >5 months later. Of the 250 patients selected with the greatest amplitude of ER 6 were excluded for electrocardiographic abnormalities, leaving 244 subjects, of whom 122 had another ECG ≥5 months later. Their average age was 42 ± 10 years and average time from the first to second ECG was 10 years. Of the 122 patients 47 (38%) retained ER, whereas most (62%) no longer fulfilled the amplitude criterion. There were no significant differences in heart rate or time interval between ECGs. In conclusion, the electrocardiographic pattern of ER was lost over 10 years in more than half of this young clinical cohort and the loss was not caused by higher heart rate, longer time between ECGs, decrease in R-wave amplitude, death, acute disease, or alterations in electrocardiographic diagnostic characteristics.