Complications related to inferior vena cava filters: a single-center experience.

We reviewed our experience with the different types of inferior vena cava (IVC) filters used over 4 years for the incidence of complications and correlated this with the type of filter used. This is a retrospective study involving chart reviews of all the patients who received IVC filters placed between January 2002 and January 2006. Data related to indications for filter insertion and the incidence of early (30 days) and late complications related to the filter insertion were collected. Complications were correlated to the type of filter and the indication for insertion. Statistical analysis was done using Fisher's exact test, and p<0.05 was considered significant. During this period 400 filters were inserted. There were 199 males (49.7%) and 201 females (50.25%). The mean patient age was 61 years (range 17-86). Filters used included TrapEase in 224 (56%), Greenfield filter in 95 (23.8%), Gunther-Tulip in 42 (10.5%), Bard recovery nitinol (all first-generation) in 34 (8.5%), and Simon Nitinol filter in five (1.2%). The indications for IVC filter insertion included acute venous thromboembolism (VTE) event in 273 patients (68.25%) and pulmonary embolism (PE) prophylaxis in 127 (31.75%) patients. In the group with VTE, 59 (21.6%) had contraindication for anticoagulation and 34 (12.5%) had hypercoagulable/malignant conditions. In the 127 patients who received the filter for PE prophylaxis in the absence of VTE, 107 (84.3%) had fractures, 43 (33.9%) had head injury, 32 (25.2%) had multiple trauma, and 15 (11.8%) had paralysis. Sixteen (12.6%) of the prophylaxis patients had IVC filter insertion prior to an elective surgical procedure. Complications in the form of hematoma at the site of filter insertion occurred in four (1%) patients, ipsilateral limb deep vein thrombosis in 15 (3.8%) patients, migration/tilt of filter in six (1.5%) patients, PE in six (1.5%) patients, and IVC thrombosis in 19 (4.75%) patients. Migration/tilt was higher in Bard filters compared to other filters, individually (p<0.004) and as a group (11.8% vs. 0.55%, p<0.0005). All other complication had a comparable incidence in all filters. However, in the group of patients (n=34) who had hypercoagulable/malignant conditions, the incidence of IVC thrombosis was higher with TrapEase filters compared to all other filters as a group (25% vs. 0%, p<0.05). In conclusion, IVC filters are frequently used for prophylaxis in the absence of VTE conditions. Complications are relatively low. All types of filters used in this study had comparable complications with the exception of the Bard filter, which had a higher incidence of tilt, and the TrapEase filter, which had a higher incidence of IVC thrombosis, in patients with hypercoagulable/malignant conditions.

Spironolactone attenuates experimental uremic cardiomyopathy by antagonizing marinobufagenin.

Spironolactone has been noted to attenuate cardiac fibrosis. We have observed that the cardiotonic steroid marinobufagenin plays an important role in the diastolic dysfunction and cardiac fibrosis seen with experimental renal failure. We performed the following studies to determine whether and how spironolactone might ameliorate these changes. First, we studied rats subjected to partial nephrectomy or administration of exogenous marinobufagenin. We found that spironolactone (20 mg/kg per day) attenuated the diastolic dysfunction as assessed by ventricular pressure-volume loops and essentially eliminated cardiac fibrosis as assessed by trichrome staining and Western blot. Next, we examined the effects of spironolactone and its major metabolite, canrenone (both 100 nM), on marinobufagenin stimulation of rat cardiac fibroblasts. Both spironolactone and canrenone prevented the stimulation of collagen production by 1 nM marinobufagenin but not 100 nM marinobufagenin, as assessed by proline incorporation and procollagen 1 expression, as well as signaling through the sodium-potassium-ATPase, as evidenced by protein kinase C isoform delta translocation and extracellular signal regulated kinase 1/2 activation. Both spironolactone and canrenone also altered ouabain binding to cultured porcine cells in a manner consistent with competitive inhibition. Our data suggest that some of the antifibrotic effects of spironolactone may be attributed to antagonism of marinobufagenin signaling through the sodium-potassium-ATPase.

Ability of the objective structured clinical examination to differentiate surgical residents, medical students, and physician assistant students.

BACKGROUND: The Objective Structured Clinical Examination (OSCE) has been used extensively to evaluate the clinical abilities of medical students and residents. The purpose of this study was to investigate whether the standard OSCE would differentiate performance of subjects with different levels and/or types of training. METHODS: We conducted a blinded OSCE, during which we simultaneously evaluated surgical residents from all 5 years of the general surgery training program, third-year medical students, and second-year physician assistant students. All examinees went through the same clinical evaluation stations, which consisted of history-taking, physical examination, technical skills, trauma management, and X-ray interpretation. The students and residents were rated at each station by a trained standardized patient evaluator or a faculty evaluator using a checklist for performance evaluation. All subjects wore surgical scrubs without name tags or identification of program or year of training. RESULTS: Overall mean performance scores (P = 0.09, NS) were for surgical residents 71.2% (+/-9.7); for medical students 66.9% (+/-5.7); for physician assistant students 64.7% (+/-5.8). This shows a significant trend toward higher scores with more training. Surgical residents scored higher on technical stations, history-taking, and X-ray interpretation. Medical students scored higher in performance of physical examination. Physician assistant students scored quite close to the other two groups. CONCLUSIONS: The differences among group performance appeared to reflect the level of experience of the learners. Some components of the OSCE appear to better differentiate levels of training.