Electrospun Chitosan-Based Nanofibrous Coating for the Local and Sustained Release of Vancomycin.

As the population ages, the number of vascular surgery procedures performed increases. Older adults often have multiple comorbidities, such as diabetes and hypertension, that increase the risk of complications from vascular surgery including vascular graft infection (VGI). VGI is a serious complication with significant morbidity, mortality, and healthcare costs. Here, we aimed to develop a nanofibrous chitosan-based coating for vascular grafts loaded with different concentrations of the vancomycin antibiotic vancomycin (VAN). Blending chitosan with poly(vinyl alcohol) or poly(ethylene oxide) copolymers improved solubility and ease of spinning. Thermal gravimetric analysis and Fourier transform infrared spectroscopy confirmed the presence of VAN in the nanofibrous membranes. Kinetics of VAN release from the nanofibrous mats were evaluated using high-performance liquid chromatography, showing a burst followed by sustained release over 24 h. To achieve longer sustained release, a poly(lactic-co-glycolic acid) coating was applied, resulting in extended release of up to 7 days. Biocompatibility assessment using human umbilical vein endothelial cells demonstrated successful attachment and viability of the nanofiber patches. Our study provides insights into the development of a drug delivery system for vascular grafts aimed at preventing infection during implantation, highlighting the potential of electrospinning as a promising technique in the field of vascular surgery.

Autologous Whole-Blood Versus Corticosteroid Local Injection in Treatment of Plantar Fasciitis: A Randomized Single Blind Placebo-Controlled Study.

BACKGROUND: Autologous whole-blood intralesional injection has attracted interest as a possible means of treatment for chronic plantar fasciitis. We contrasted its effectiveness with that of corticosteroids, which have a longer history of success in treating tendinopathies such as plantar fasciitis. In order to monitor the disease's progress naturally, we also compared them with a placebo. METHODS: Sixty clinically diagnosed patients were taken up for intralesional injection of autologous whole blood (AWB), corticosteroid, and normal saline as placebo mixed with 2 mL of lignocaine after dividing them into three groups. Two doses were given and followed up in the third, sixth, and 12th weeks. The evaluation was done according to the visual analog scale (VAS) and the number of tablets of paracetamol (PCM) 500 mg consumed for the following period. RESULTS: When compared to the placebo group in the third, sixth, and 12th weeks, the corticosteroid group exhibited a significant improvement with a p<0.001 in the VAS score, whereas the autologous whole blood group showed no meaningful difference. When compared to the placebo group at the sixth and 12th weeks, the AWB group's VAS score showed a statistically significant difference with a p>0.001. At each follow-up, the placebo group consumed more analgesics than the corticosteroid group, with a p<0.001. Only in the third week of follow-up did AWB demonstrate a statistically significant difference in PCM consumption as compared to the corticosteroid group. CONCLUSION: Statistically significant improvement was seen in both the AWB group and corticosteroid group as compared to the placebo group. The corticosteroid group achieved earlier and superior relief of pain while AWB had a longer lasting effect. Therefore, study results indicate almost similar results in short-term studies.

Internal iliac artery aneurysm masquerading as a sciatic nerve schwannoma: illustrative case.

BACKGROUND: Schwannomas are common peripheral nerve sheath tumors. Imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT) can help to distinguish schwannomas from other types of lesions. However, there have been several reported cases describing the misdiagnosis of aneurysms as schwannomas. OBSERVATIONS: A 70-year-old male with ongoing pain despite spinal fusion surgery underwent MRI. A lesion was noted along the left sciatic nerve, which was believed to be a sciatic nerve schwannoma. During the surgery for planned neurolysis and tumor resection, the lesion was noted to be pulsatile. Electromyography mapping and intraoperative ultrasound confirmed vascular pulsations and turbulent flow within the aneurysm, so the surgery was aborted. A formal CT angiogram revealed the lesion to be an internal iliac artery (IIA) branch aneurysm. The patient underwent coil embolization with complete obliteration of the aneurysm. LESSONS: The authors report the first case of an IIA aneurysm misdiagnosed as a sciatic nerve schwannoma. Surgeons should be aware of this potential misdiagnosis and potentially use other imaging modalities to confirm the lesion before proceeding with surgery.

An unusual recurrent case of Cryptococcal sacroiliitis in an immunocompetent elderly female in Rajasthan, India.

A 70-year-old female presented with left sided low back pain. There was no history of any co-morbidities or immunocompromised state. Skeletal cryptococcosis was confirmed bsaed on culture and histopathology, along with pulmonary involvement. After a month of oral antifungal therapy, the patient's symptoms resolved, but an abscess relapsed at the same site, which was treated with a combination of IV Amphotericin B and 5-flucytosine followed by oral fluconazole, with no recurrence or complaints reported in subsequent follow-up.

Leflunomide treatment for patients hospitalised with COVID-19: DEFEAT-COVID randomised controlled trial.

OBJECTIVE: To evaluate the clinical efficacy and safety of leflunomide (L) added to the standard-of-care (SOC) treatment in COVID-19 patients hospitalised with moderate/critical clinical symptoms. DESIGN: Prospective, open-label, multicentre, stratified, randomised clinical trial. SETTING: Five hospitals in UK and India, from September 2020 to May 2021. PARTICIPANTS: Adults with PCR confirmed COVID-19 infection with moderate/critical symptoms within 15 days of onset. INTERVENTION: Leflunomide 100 mg/day (3 days) followed by 10-20 mg/day (7 days) added to standard care. PRIMARY OUTCOMES: The time to clinical improvement (TTCI) defined as two-point reduction on a clinical status scale or live discharge prior to 28 days; safety profile measured by the incidence of adverse events (AEs) within 28 days. RESULTS: Eligible patients (n=214; age 56.3±14.9 years; 33% female) were randomised to SOC+L (n=104) and SOC group (n=110), stratified according to their clinical risk profile. TTCI was 7 vs 8 days in SOC+L vs SOC group (HR 1.317; 95% CI 0.980 to 1.768; p=0.070). Incidence of serious AEs was similar between the groups and none was attributed to leflunomide. In sensitivity analyses, excluding 10 patients not fulfilling the inclusion criteria and 3 who withdrew consent before leflunomide treatment, TTCI was 7 vs 8 days (HR 1.416, 95% CI 1.041 to 1.935; p=0.028), indicating a trend in favour of the intervention group. All-cause mortality rate was similar between groups, 9/104 vs 10/110. Duration of oxygen dependence was shorter in the SOC+L group being a median 6 days (IQR 4-8) compared with 7 days (IQR 5-10) in SOC group (p=0.047). CONCLUSION: Leflunomide, added to the SOC treatment for COVID-19, was safe and well tolerated but had no major impact on clinical outcomes. It may shorten the time of oxygen dependence by 1 day and thereby improve TTCI/hospital discharge in moderately affected COVID-19 patients. TRIAL REGISTRATION NUMBERS: EudraCT Number: 2020-002952-18, NCT05007678.

Houston Methodist Ruptured Abdominal Aortic Aneurysm Guidelines.

Ruptured abdominal aortic aneurysm (RAAA) is an acute aortic condition that requires emergent intervention and appropriate continuity of care to optimize patient outcomes. We describe the standardized RAAA protocol at the Houston Methodist Hospital Acute Aortic Treatment Center, developed to navigate critical patient transfer periods safely and efficiently, make crucial decisions about surgical intervention, and clearly communicate these plans with other care team providers. Our workflow is organized into five phases: prehospital, preoperative, intraoperative, postoperative, and post-discharge. We identify the transfer center, anesthesia, operating room nursing staff, surgeons, and intensive care unit as key entities of our acute aortic pathology care team. This systematic protocol for the management of acute aortic emergencies such as RAAA identifies critical decision points, potential complications at each stage, and recommendations for best practice.

A complete biomechanical model of Hydra contractile behaviors, from neural drive to muscle to movement.

How does neural activity drive muscles to produce behavior? The recent development of genetic lines in Hydra that allow complete calcium imaging of both neuronal and muscle activity, as well as systematic machine learning quantification of behaviors, makes this small cnidarian an ideal model system to understand and model the complete transformation from neural firing to body movements. To achieve this, we have built a neuromechanical model of Hydra's fluid-filled hydrostatic skeleton, showing how drive by neuronal activity activates distinct patterns of muscle activity and body column biomechanics. Our model is based on experimental measurements of neuronal and muscle activity and assumes gap junctional coupling among muscle cells and calcium-dependent force generation by muscles. With these assumptions, we can robustly reproduce a basic set of Hydra's behaviors. We can further explain puzzling experimental observations, including the dual timescale kinetics observed in muscle activation and the engagement of ectodermal and endodermal muscles in different behaviors. This work delineates the spatiotemporal control space of Hydra movement and can serve as a template for future efforts to systematically decipher the transformations in the neural basis of behavior.

Retained ureteral stents, an avoidable source of morbidity: 10 years´ experience from a single tertiary care centre.

Introduction: ureteral stents are used in managing various urological conditions. When these stents are left indwelling for a prolonged time, it results in complications like stent migration, fragmentation, and encrustation. The aim of this retrospective observational study is to analyse the incidence, risk factors, and morbidity associated with retained ureteral stents. Methods: the retained/forgotten ureteral stents were defined as the stents with an indwelling period of more than six months. The records of all such patients from January 2010 to January 2020 were retrospectively reviewed. The primary reason for the placement of a stent, total indwelling time, the reason for prolonged indwelling time, and part(s) of the stent encrusted were retrospectively reviewed. Single/multistage endourological procedures were used to make the patients remove the retained stents and stone free. The type, number of procedures, and total number of sessions needed were noted. Results: data of 114 patients was reviewed retrospectively. Most patients presented with abdominal pain (62 patients, 54.4%), and dysuria (41 patients, 35.1%). An average of 1.7 sessions (range 1-4) were needed to make the patients' stent and stone free. During these sessions, single/multiple procedures (endoscopic/open/combined) were performed. Nine patients (7.9%) had permanent loss of renal unit function and who needed a nephrectomy. Poor compliance (45.6%), unawareness (35.1%), and misconception that the stent would last a lifetime (12.3%), were the most common reasons for retained ureteral stents. The incidence rate of retained stents fell from 1.1% to 0.5% after the "three steps" prevention check method was in-cooperated to ensure timely follow-up of the patients. Conclusion: retained ureteral stents are a significant source of morbidity, which is avoidable by ensuring timely removal. Sincere efforts should be made to make patients aware of an indwelling foreign body. Prevention is the best strategy.

A multi modal approach to microstructure evolution and mechanical response of additive friction stir deposited AZ31B Mg alloy.

Current work explored solid-state additive manufacturing of AZ31B-Mg alloy using additive friction stir deposition. Samples with relative densities ≥ 99.4% were additively produced. Spatial and temporal evolution of temperature during additive friction stir deposition was predicted using multi-layer computational process model. Microstructural evolution in the additively fabricated samples was examined using electron back scatter diffraction and high-resolution transmission electron microscopy. Mechanical properties of the additive samples were evaluated by non-destructive effective bulk modulus elastography and destructive uni-axial tensile testing. Additively produced samples experienced evolution of predominantly basal texture on the top surface and a marginal increase in the grain size compared to feed stock. Transmission electron microscopy shed light on fine scale precipitation of Mg[Formula: see text]Al[Formula: see text] within feed stock and additive samples. The fraction of Mg[Formula: see text]Al[Formula: see text] reduced in the additively produced samples compared to feed stock. The bulk dynamic modulus of the additive samples was slightly lower than the feed stock. There was a [Formula: see text] 30 MPa reduction in 0.2% proof stress and a 10-30 MPa reduction in ultimate tensile strength for the additively produced samples compared to feed stock. The elongation of the additive samples was 4-10% lower than feed stock. Such a property response for additive friction stir deposited AZ31B-Mg alloy was realized through distinct thermokinetics driven multi-scale microstructure evolution.

Chest radiographs may assist in predicting the outcome in the early phase of Covid-19. UK district general hospital experience of Covid-19 first wave.

Objectives: Severe Acute Respiratory Syndrome coronavirus-2 (SARS-CoV-2) has caused enormous strain on health-care systems worldwide. Early recognition of prognostic markers and appropriate management of patients with coronavirus disease 2019 (Covid-19) remains a major global health concern, particularly when resources are limited. We undertook a study to see if basic tests can inform frontline clinicians of disease trajectory in individual patients with COVID-19.Methods: We retrospectively assessed characteristics of the first 50 consecutive patients admitted to district general hospital in the United Kingdom with positive SARS-Cov-2 RNA swabs.Results: Our patient cohort shared broad similarities with previously published data on comorbidities and presenting features. We have found that chest radiographic assessment differed between survivors and non-survivors. Air space shadowing in middle zones were more prevalent in non-survivors (73.3% vs. 35.5% [p = 0.027]). Chest radiograph severity score was also found to be higher in non-survivors compared to survivors (3 vs. 1.5 [p = 0.007]).Conclusions: In this small retrospective study, our results suggest features of chest radiographs at presentation may provide a helpful tool for prognostication. In environments with constrained computed tomography (CT) imaging with serial chest radiographs could be a cost-effective tool in the assessment of Covid-19 patients.

Serious Gastrointestinal Complications After Cardiac Surgery and Associated Mortality.

BACKGROUND: Severe gastrointestinal (GI) complications (GICs) after cardiac surgery are associated with poor outcomes. Herein, we characterize the severe forms of GICs and associated risk factors of mortality. METHODS: We retrospectively analyzed the clinically significant postoperative GICs after cardiac surgical procedures performed at our institution from January 2010 to April 2017. Multivariable analysis was used to identify predictors for in-hospital mortality. RESULTS: Of 29,909 cardiac surgical procedures, GICs occurred in 1037 patients (3.5% incidence), with overall in-hospital mortality of 14% compared with 1.6% in those without GICs. GICs were encountered in older patients with multiple comorbidities who underwent complex prolonged procedures. The most lethal GICs were mesenteric ischemia (n = 104), hepatopancreatobiliary (HPB) dysfunction (n = 139), and GI bleeding (n = 259), with mortality rates of 45%, 27%, and 17%, respectively. In the mesenteric ischemia subset, coronary artery disease (odds ratio [OR], 4.57; P = .002], coronary bypass grafting (OR, 6.50; P = .005), reoperation for bleeding/tamponade (OR, 12.07; P = .01), and vasopressin use (OR, 11.27; P < .001) were predictors of in-hospital mortality. In the HPB complications subset, hepatic complications occurred in 101 patients (73%), pancreatitis in 38 (27%), and biliary disease in 31 (22%). GI bleeding occurred in 20 patients (31%) with HPB dysfunction. In the GI bleeding subset, HPB disease (OR, 10.99; P < .001) and bivalirudin therapy (OR, 12.84; P = .01) were predictors for in-hospital mortality. CONCLUSIONS: Although relatively uncommon, severe forms of GICs are associated with high mortality. Early recognition and aggressive treatment are mandatory to improve outcomes.

Concomitant ipsilateral carotid endarterectomy and stenting is an effective treatment for tandem carotid artery lesions.

OBJECTIVE: Data regarding the treatment of tandem carotid artery lesions at the bifurcation and ipsilateral, proximal common carotid artery (CCA) are limited. It has been suggested that concomitant treatment with carotid endarterectomy (CEA) and proximal ipsilateral carotid artery stenting confers a high risk of stroke and death. The objective of this study was to evaluate the technique and outcomes of this hybrid procedure at a single institution. METHODS: A retrospective chart review was performed including patients who underwent CEA + ipsilateral carotid artery stenting for treatment of atherosclerotic carotid artery disease between December 2007 and April 2017. Primary endpoints were postoperative myocardial infarction, neurologic event, and perioperative mortality. RESULTS: Twenty-two patients (15 male [68%]) underwent CEA + ipsilateral carotid artery stenting with a mean follow-up of 67 ± 77 months. The mean age was 70.0 ± 6.1 years old, all with a prior smoking history (eight current smokers [64%]). Twelve patients (55%) were treated for symptomatic disease and three had a prior ipsilateral CEA (one also with CAS). Computed tomographic angiography imaging was performed preoperatively in 21 patients (95%). CEA was performed first in 18 patients (82%) followed by ipsilateral carotid artery stenting. CEA was performed with a patch in 20 and eversion endarterectomy in two patients. Ipsilateral CCA was stented in 21 patients (96%) and one innominate was stented in a patient with a right CEA. Additional endovascular interventions were performed in three patients: 1 innominate stent, 1 distal ipsilateral internal carotid artery stent, and 1 right subclavian artery stent. All proximal stents were placed with sheath access through the endarterectomy patch in 12 (55%), CCA in 7 (32%), and through the arteriotomy before patching in 3 (14%). Distal internal carotid artery clamping was performed in 18 (90%, available 20) of patients before ipsilateral carotid artery stenting. All proximal lesions were successfully treated endovascularly with no open conversion. One dissection was created and treated effectively with stenting. One perioperative stroke (4.5%) occurred in a patient treated for symptomatic disease, 1 postoperative myocardial infarction (4.5%), and 2 patients (9.1%) with cranial nerve injuries. There was one patient who expired within 30 days, shortly after discharge for unknown reasons. The mean length of stay was 2.6 ± 2.0 days. CONCLUSIONS: In appropriately selected patients, concomitant CEA and ipsilateral carotid artery stenting can be safely performed in high-risk patients with a low risk of myocardial infarction, neurologic events, and perioperative mortality when careful surgical technique is used, using direct carotid access, and distal carotid clamping for cerebral protection before stenting.

Biliary Mucinous Cystic Neoplasm: a Classic Presentation of a Rare Neoplasm.

Biliary mucinous cystic neoplasms are rare parenchymal neoplasms with a considerable malignant potential. Due to a lack of diagnostic imaging criteria, histopathologic evaluation remains the definitive method of diagnosis. Resection is the treatment of choice. Here, the authors present a case of biliary mucinous neoplasm in a 39-year-old female with the associated radiographic and histopathologic findings.

A novel, highly discriminatory risk model predicting acute severe right ventricular failure in patients undergoing continuous-flow left ventricular assist device implant.

Various risk models with differing discriminatory power and predictive accuracy have been used to predict right ventricular failure (RVF) after left ventricular assist device (LVAD) placement. There remains an unmet need for a contemporary risk score for continuous flow (CF)-LVADs. We sought to independently validate and compare existing risk models in a large cohort of patients and develop a simple, yet highly predictive risk score for acute, severe RVF. Data from the Mechanical Circulatory Support Research Network (MCSRN) registry, consisting of patients who underwent CF-LVAD implantation, were randomly divided into equal-sized derivation and validation samples. RVF scores were calculated for the entire sample, and the need for a right ventricular assist device (RVAD) was the primary endpoint. Candidate predictors from the derivation sample were subjected to backward stepwise logistic regression until the model with lowest Akaike information criterion value was identified. A risk score was developed based on the identified variables and their respective regression coefficients. Between May 2004 and September 2014, 734 patients underwent implantation of CF-LVADs [HeartMate II LVAD, 76% (n = 560), HeartWare HVAD, 24% (n = 174)]. A RVAD was required in 4.5% (n = 33) of the patients [Derivation cohort, n = 15 (4.3%); Validation cohort, n = 18 (5.2%); P = 0.68)]. 19.5% of the patients (n = 143) were female, median age at implant was 59 years (IQR, 49.4-65.3), and median INTERMACS profile was 3 (IQR, 2-3). RVAD was required in 4.5% (n = 33) of the patients. Correlates of acute, severe RVF in the final model included heart rate, albumin, BUN, WBC, cardiac index, and TR severity. Areas under the curves (AUC) for most commonly used risk predictors ranged from 0.61 to 0.78. The AUC for the new model was 0.89 in the derivation and 0.92 in the validation cohort. Proposed risk model provides very high discriminatory power predicting acute severe right ventricular failure and can be reliably applied to patients undergoing placement of contemporary continuous flow left ventricular assist devices.

The influence of lymphoid reconstitution kinetics on clinical outcomes in allogeneic stem cell transplantation.

Lymphoid recovery following myeloablative stem cell transplantation (SCT) displays a logistic pattern of exponential growth followed by a plateau. Within this logistic framework, lymphoid recovery is characterized by the parameters R (slope of ascent), a (time of maximal rate of ascent) and K (plateau), the 'steady-state' lymphocyte count. A retrospective analysis of allogeneic SCT performed from 2008 to 2013 was undertaken to compare lymphoid recovery and clinical outcomes in 131 patients with acute myelogenous leukemia, acute lymphocytic leukemia, and myelodysplastic syndromes. Using Prism software, a logistic curve was successfully fit to the absolute lymphocyte count recovery in all patients. Patients were classified according to the magnitude and rate of lymphoid recovery; pattern A achieved an absolute lymphocyte counts (ALC) of >1000/µL by day 45, pattern B an ALC 500 < x < 1000/µL, and pattern C an ALC <500/µL. Pattern A was characterized by a higher mean K (p < .0001) compared with patterns B and C. Patients with patterns B and C were more likely to have mixed T cell chimerism at 90 d following SCT (p = .01). There was a trend towards improved survival (and relapse-free survival) in those with pattern A and B at 1 year compared to pattern C (p = .073). There was no difference in cGVHD (p = .42) or relapse (p = .45) between pattern types. Cytomegalovirus (CMV), aGVHD, and all relapse were heralded by deviation from logistic behavior. Pattern C patients were more likely to require donor lymphocyte infusion (DLI) (p = .017). Weaning of tacrolimus post-transplant was associated with a second, separate logistic expansion in some patients. This study demonstrated that lymphoid reconstitution follows a prototypical logistic recovery and that pattern observed correlates with T cell chimerism and need for DLI, and may influence survival.

Sensitive and rapid detection of pathogenic bacteria in small volumes using impedance spectroscopy technique.

We illustrate a novel impedance immunosensor which rapidly and sensitively detects typhoid-causing infectious bacteria Salmonella enterica serovar (Salmonella typhi) in 10 µL of sample volume. The bacteria are tagged with gold nanoparticles (Au NPs) via high-affinity antigen-antibody interactions for enhanced signal amplification and selectivity. The cell-particle bioconjugates are then subjected to alternating current (AC) electric fields applied through interdigitated microelectrodes. The immunosensor performance is optimized with respect to electric field frequency, cell concentration, incubation times and the type of blocking agent to achieve a low limit of detection (LOD) of 100 CFU/mL. The approach is extendable to a wide spectrum of clinical diseases and offers an efficient and cost-effective solution for point-of-care diagnosis.

Treatment of device thrombus in the HeartWare HVAD: Success and outcomes depend significantly on the initial treatment strategy.

BACKGROUND: Pump thrombosis is a major adverse event in patients supported with a left ventricular assist device (LVAD). Treatment approaches include device exchange, lytic therapy, or augmentation of anticoagulation or antiplatelet therapy. The optimal strategy in the HeartWare HVAD Ventricular Assist System (HeartWare, Framingham, MA) is uncertain, and because few large studies have examined differing treatment outcomes, we have reviewed findings from the Mechanical Circulatory Support Research Network registry. METHODS: Between March 2009 and August 2014, 175 patients (133 male) underwent implantation of the HeartWare HVAD at institutions that comprise the Mechanical Circulatory Support Research Network. Median age at implant was 59 years (range, 18-76 years). Follow-up was available in all patients for a median of 6 months (maximum, 61 months) and for a total of 163 patient-years of support. There were 36 pump thromboses (using Interagency Registry for Mechanically Assisted Circulatory Support criteria) in 21 patients for a total event rate of 0.22 events/patient-year of support; 13 patients had 1 event, 4 had 2, 2 had 3, 1 had 4, and 1 had 5. The median time to the first thrombosis was 6.4 months, and to each subsequent thrombosis was 4, 3, 2, and 2 months, respectively. Primary treatment success was defined as the patient remaining alive and within the first 30 days of the initial treatment be free from stroke, recurrence of pump thrombosis, device exchange, or urgent transplantation (United Network of Organ Sharing Status 1A). Medical treatment was defined as tissue plasminogen activator, heparin plus glycoprotein IIb/IIIa inhibitor, or heparin alone, not followed by surgical treatment within 72 hours. RESULTS: Initial medical treatment was used in 29 episodes (tissue plasminogen activator in 24, heparin alone in 4, and heparin plus glycoprotein IIb/IIIa in 1) and surgical (device exchange) in 7. Medical treatment was successful in 14 of 29 episodes (48%). Complications of medical treatment included hemorrhagic stroke in 6 patients (21%), need for urgent device exchange/transplant in 6 (21%), and death in 3 (10%). Surgical treatment was successful in all 7 patients (100%). No significant early complications or early deaths occurred after device exchange. CONCLUSIONS: In this large multicenter analysis, we observed that medical therapy, as the initial treatment strategy for HeartWare HVAD thrombosis, is associated with low success (48%) and a significant risk of hemorrhagic stroke (21%) and death (10%). However, initial treatment with device exchange was uniformly successful and not associated with significant early morbidity or death. Although the optimal treatment approach for HeartWare HVAD pump thrombosis remains undecided, these data do not support the routine use of medical therapy as an initial treatment strategy.

Psychosocial characteristics and outcomes in patients with left ventricular assist device implanted as destination therapy.

BACKGROUND: Psychosocial factors impact survival in patients undergoing cardiac transplantation, but it is unclear whether they affect outcomes in patients undergoing left ventricular assist device (LVAD) implantation as destination therapy (DT). METHODS: Patients undergoing DT LVAD at the Mayo Clinic in Rochester, MN, from February 2007 to December 2013 were included. Psychosocial characteristics at the time of LVAD implantation were abstracted from the medical record. Andersen-Gill and Cox models were used to examine the association between psychosocial characteristics and all-cause readmission and death, respectively. Patients were censored at death or last follow-up through September 2014. RESULTS: Among 136 patients (mean age. 64 years; 17% female), most were married/living with a partner (82%), half (55%) had post-high school education, and a history of depression was common (32%). Although most patients were former tobacco users (60%) only a small proportion were current tobacco users (10%) and had a history of alcohol abuse (16%) or illegal drug use (7%). After a mean follow-up of 2.2 ± 1.8 years, 78% of patients had been readmitted (range, 0-14 per person) and 49% had died. There were no statistically significant differences in the risk of death according to psychosocial characteristics. However, current tobacco users had lower risk of readmission (adjusted HR, 0.57; 95% CI, 0.38-0.88), while illegal drug use (HR, 1.55; 95% CI, 1.01-2.35) and depression (HR, 1.77; 95% CI, 1.40-2.22) were associated with higher readmission risk. CONCLUSIONS: Psychosocial characteristics are not significant predictors of death but are associated with readmission risk after DT LVAD.

Management of pump thrombosis in patients with left ventricular assist devices.

The gradual evolution of left ventricular assist device (LVAD) therapy has resulted in a durable option for patients as either a bridge to transplantation (BTT) or a destination therapy (DT). Outcomes with current continuous-flow devices continue to demonstrate significant patient benefit, not only in enhanced survival but also in improved functional capacity and quality of life. While the lessening of adverse events through time has resulted in more widespread adoption of this therapy, there continues to be unintended consequences, including, most notably, infection, bleeding, and thrombosis. Beginning in 2011, centers and collaborative groups began to observe a significant increase in the incidence of pump thrombosis with the HeartMate II LVAD (Thoratec Corp., Pleasanton, CA, USA). However, this clinical scourge is not limited to the HeartMate II, as the HeartWare Ventricular Assist System (HVAD; HeartWare Inc., Framingham, MA, USA) has also had these same issues, which led to pump modifications and the appreciation of more strict control of blood pressure and anticoagulation with this pump design. We review the current status of the field of mechanical circulatory support in its approach to diagnosis, management, and prevention of LVAD pump thrombosis.