Cerebrovascular Events in Patients With Centrifugal-Flow Left Ventricular Assist Devices: Propensity Score-Matched Analysis From the Intermacs Registry.

BACKGROUND: Ischemic and hemorrhagic cerebrovascular accidents remain common among patients with centrifugal-flow left ventricular assist devices, despite improvements in survival and device longevity. We compared the incidence of neurologic adverse events (NAEs) associated with 2 contemporary centrifugal-flow left ventricular assist devices: the Abbott HeartMate3 (HM3) and the Medtronic HeartWare HVAD (HVAD). METHODS: Using the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs), we collected data on adult patients who received a centrifugal-flow left ventricular assist device as a primary isolated implant between January 1, 2017, and September 30, 2019. Major NAEs were defined as transient ischemic attack, ischemic cerebrovascular accident, or hemorrhagic cerebrovascular accident. The association of HVAD with risk of NAE in the first year after implant was evaluated using propensity score matching to balance for preimplant risk factors. After matching, freedom from first major NAE in the HM3 and HVAD cohorts was compared with Kaplan-Meier curves. A secondary analysis using multivariable multiphase hazard models was used to identify predictors of NAE, which uses a data-driven parametric fit of the early declining and constant phase hazards and the associations of risk factor with either phase. RESULTS: Of 6205 included patients, 3129 (50.4%) received the HM3 and 3076 (49.6%) received the HVAD. Median follow-up was 9 and 12 months (HM3 and HVAD, respectively). Patients receiving HVAD had more major NAEs (16.4% versus 6.4%, P<0.001) as well as each subtype (transient ischemic attack: 3.3% versus 1.0%, P<0.001; ischemic cerebrovascular accident: 7.7% versus 3.4%, P<0.001; hemorrhagic cerebrovascular accident: 7.2% versus 2.0%, P<0.001) than did patients receiving HM3. A propensity-matched cohort balanced for preimplant risk factors showed that HVAD was associated with higher probabilities of major NAEs (% freedom from NAE 82% versus 92%, P<0.001). Device type was not significantly associated with NAEs in the early hazard phase, but HVAD was associated with higher incidence of major NAEs during the constant hazard phase (hazard ratio, 5.71 [CI, 3.90-8.36]). CONCLUSIONS: HM3 is associated with lower hazard of major NAEs than is HVAD beyond the early postimplantation period and during the constant hazard phase. Defining the explanation for this observation will inform device selection for individual patients.

Cerebrovascular Events in Patients With Centrifugal-Flow Left Ventricular Assist Devices: Propensity Score-Matched Analysis From the Intermacs Registry.

BACKGROUND: Ischemic and hemorrhagic cerebrovascular accidents remain common among patients with centrifugal-flow left ventricular assist devices, despite improvements in survival and device longevity. We compared the incidence of neurologic adverse events (NAEs) associated with 2 contemporary centrifugal-flow left ventricular assist devices: the Abbott HeartMate3 (HM3) and the Medtronic HeartWare HVAD (HVAD). METHODS: Using the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs), we collected data on adult patients who received a centrifugal-flow left ventricular assist device as a primary isolated implant between January 1, 2017, and September 30, 2019. Major NAEs were defined as transient ischemic attack, ischemic cerebrovascular accident, or hemorrhagic cerebrovascular accident. The association of HVAD with risk of NAE in the first year after implant was evaluated using propensity score matching to balance for preimplant risk factors. After matching, freedom from first major NAE in the HM3 and HVAD cohorts was compared with Kaplan-Meier curves. A secondary analysis using multivariable multiphase hazard models was used to identify predictors of NAE, which uses a data-driven parametric fit of the early declining and constant phase hazards and the associations of risk factor with either phase. RESULTS: Of 6205 included patients, 3129 (50.4%) received the HM3 and 3076 (49.6%) received the HVAD. Median follow-up was 9 and 12 months (HM3 and HVAD, respectively). Patients receiving HVAD had more major NAEs (16.4% versus 6.4%, P<0.001) as well as each subtype (transient ischemic attack: 3.3% versus 1.0%, P<0.001; ischemic cerebrovascular accident: 7.7% versus 3.4%, P<0.001; hemorrhagic cerebrovascular accident: 7.2% versus 2.0%, P<0.001) than did patients receiving HM3. A propensity-matched cohort balanced for preimplant risk factors showed that HVAD was associated with higher probabilities of major NAEs (% freedom from NAE 82% versus 92%, P<0.001). Device type was not significantly associated with NAEs in the early hazard phase, but HVAD was associated with higher incidence of major NAEs during the constant hazard phase (hazard ratio, 5.71 [CI, 3.90-8.36]). CONCLUSIONS: HM3 is associated with lower hazard of major NAEs than is HVAD beyond the early postimplantation period and during the constant hazard phase. Defining the explanation for this observation will inform device selection for individual patients.

Uroplakins do not restrict CO2 transport through urothelium.

Lipid bilayers and biological membranes are freely permeable to CO(2), and yet partial CO(2) pressure in the urine is 3-4-fold higher than in blood. We hypothesized that the responsible permeability barrier to CO(2) resides in the umbrella cell apical membrane of the bladder with its dense array of uroplakin complexes. We found that disrupting the uroplakin layer of the urothelium resulted in water and urea permeabilities (P) that were 7- to 8-fold higher than in wild type mice with intact urothelium. However, these interventions had no impact on bladder P(CO2) (∼1.6 × 10(-4) cm/s). To test whether the observed permeability barrier to CO(2) was due to an unstirred layer effect or due to kinetics of CO(2) hydration, we first measured the carbonic anhydrase (CA) activity of the bladder epithelium. Finding none, we reduced the experimental system to an epithelial monolayer, Madin-Darby canine kidney cells. With CA present inside and outside the cells, we showed that P(CO2) was unstirred layer limited (∼7 × 10(-3) cm/s). However, in the total absence of CA activity P(CO2) decreased 14-fold (∼ 5.1 × 10(-4) cm/s), indicating that now CO(2) transport is limited by the kinetics of CO(2) hydration. Expression of aquaporin-1 did not alter P(CO2) (and thus the limiting transport step), which confirmed the conclusion that in the urinary bladder, low P(CO2) is due to the lack of CA. The observed dependence of P(CO2) on CA activity suggests that the tightness of biological membranes to CO(2) may uniquely be regulated via CA expression.

Occupational therapy consultation for case managers in community mental health: exploring strategies to improve job satisfaction and self-efficacy.

UNLABELLED: The purpose of this study was 2-fold: (1) to examine to what extent case managers' job satisfaction and self-efficacy were impacted by the addition of an occupational therapy consultation model and (2) to identify factors that both positively and negatively impacted the occupational therapy consultation services. PRIMARY PRACTICE SETTING: The study was conducted at a mental health community support program in a local homeless center. METHODOLOGY AND SAMPLE: In a 2-year study, a mixed-methods design was used to study changes over time in job satisfaction and perceived self-efficacy among 14 case managers who received ongoing occupational therapy consultation. Job satisfaction and self-efficacy data were obtained using standardized questionnaires. Qualitative data related to factors impacting the consultation program were obtained using open-ended written questions, focus groups, and individual interviews. RESULTS: Statistically significant differences in job satisfaction and perceptions of self-efficacy were found 18 months into the study, when case managers were more actively seeking occupational therapy consultation services and were reporting improved client outcomes from occupational therapy intervention. In addition, themes related to both positive and negative factors impacting the occupational therapy consultation program were identified and provided useful data for development of future consultation services. IMPLICATION FOR CASE MANAGEMENT PRACTICE: Results suggest that ongoing training and professional support for case managers who are paraprofessionals and/or new to mental health practice may improve job satisfaction and efficacy. Occupational therapy consultation may be helpful in developing services for health promotion, including self-care management, cognitive assessments, activity-based programming, and home safety evaluation and modification. In addition, new graduates and paraprofessional case managers working with clients who are high utilizers of services may benefit from smaller caseloads and support from clinical professionals.

Successful reduction of surgeries secondary to arterial access site complications: a retrospective review at a single center with an extravascular closure device.

BACKGROUND: Access site complications requiring emergent surgery following femoral catheterization expose patients to additional morbidities and mortality. We observed a significant decrease in such surgeries after the Mynx device was introduced. METHODS: A retrospective review of surgeries performed as a complication of 6F & 7F femoral cardiac and peripheral catheterization was done. Rates of surgeries among 3 closure methods were compared during the study period July 2006 to July 2008 (Mynx, AngioSeal, and manual/mechanical compression). RESULTS: Of 11 006 6F &7F transfemoral catheterization procedures, 26 (0.24%) surgeries secondary to access complications resulted. Surgeries were done in 14 (0.61%) AngioSeal patients, 10 (0.19%) manual/mechanical compression, and 2 (0.06%) Mynx patients (P < .0001 vs AngioSeal, P = .14 vs compression). CONCLUSIONS: Significant reduction in surgeries was seen in the Mynx vs Angioseal patients, no difference was noted in compression subset. Further analysis is warranted to prospectively evaluate these findings.

CEO compensation now under the microscope.

As hospitals brace for weaker performance outcomes and decreased revenues, boards are asking how such downturns may affect their executive compensation incentive plans.

Retail renaissance.

FINANCE: Hospital gift shops are reinventing themselves as booming retail operations. FINANCE: The AHA's report on the capital crisis' impact on hospitals.

The total picture: developing a patient experience.

The correlation between a patient's level of engagement with a hospital and brand loyalty led the Cleveland Clinic to develop a new C-suite position: the chief experience officer.

Cultivating trust: the board-medical staff relationship.

To achieve better quality and safety outcomes, boards and their medical staffs must overcome a relationship often fraught with tension and distrust in order to forge a new partnership.

A different voice: nurses on the board.

While physicians are common as trustees, relatively few nurses sit at the board table. But in an era of quality and patient safety, the time may be at hand to add the nurses' voice to governance deliberations.

Urinary bladder function and somatic sensitivity in vasoactive intestinal polypeptide (VIP)-/- mice.

Vasoactive intestinal polypeptide (VIP) is an immunomodulatory neuropeptide widely distributed in neural pathways that regulate micturition. VIP is also an endogenous anti-inflammatory agent that has been suggested for the development of therapies for inflammatory disorders. In the present study, we examined urinary bladder function and hindpaw and pelvic sensitivity in VIP(-/-) and littermate wildtype (WT) controls. We demonstrated increased bladder mass and fewer but larger urine spots on filter paper in VIP(-/-) mice. Using cystometry in conscious, unrestrained mice, VIP(-/-) mice exhibited increased void volumes and shorter intercontraction intervals with continuous intravesical infusion of saline. No differences in transepithelial resistance or water permeability were demonstrated between VIP(-/-) and WT mice; however, an increase in urea permeability was demonstrated in VIP(-/-) mice. With the induction of bladder inflammation by acute administration of cyclophosphamide, an exaggerated or prolonged bladder hyperreflexia and hindpaw and pelvic sensitivity were demonstrated in VIP(-/-) mice. The changes in bladder hyperreflexia and somatic sensitivity in VIP(-/-) mice may reflect increased expression of neurotrophins and/or proinflammatory cytokines in the urinary bladder. Thus, these changes may further regulate the neural control of micturition.

Take heed. How patient and family advisors can improve quality.

Hospitals are realizing the value of creating patient and family advisory councils, not only to improve quality throughout the organization but also to increase safety by involving patients and their families more directly in care decisions.

Hospitals weigh in on quality.

The board's role in quality oversight is growing more important every day, not only because it's the right thing to do, but also because pay for performance and increasing demands for transparency are requiring more accountability.

Studies on localization and function of annexin A4a within urinary bladder epithelium using a mouse knockout model.

Annexin A4 (anxA4) is a member of the Ca(2+)-dependent membrane-binding family of proteins implicated in the regulation of ion conductances, Ca(2+) homeostasis, and membrane trafficking. We demonstrate, in mice, that annexins 1-6 are present in whole bladder and exhibit differential expression in the urothelium. An anxA4a-knockout (anxA4a(-/-)) mouse model shows no protein in the urothelium by immunofluorescence and immunoblotting. In wild-type bladders, anxA4a in umbrella cells showed uniform cytoplasmic staining and some association with the nuclear membrane. Application of a hydrostatic pressure to bladders mounted in Ussing chambers resulted in redistribution of anxA4a from cytoplasm to cellular boundaries in the basal and intermediate cells but not in superficial umbrella cells. We hypothesized that anxA4a might be important for barrier function or for stretch-activated membrane trafficking. To test these hypotheses, we conducted a series of functional and morphological analyses on bladders from control and anxA4a(-/-) animals. The transepithelial resistances, water permeabilities, and urea permeabilities of anxA4a(-/-) bladders were not different from controls, indicating that barrier function was intact. Membrane trafficking in response to hydrostatic pressure as measured by capacitance increases was also normal for anxA4a(-/-) bladders. Cystometrograms performed on live animals showed that voiding frequency and intrabladder pressures were also not different. There were no differences in bladder surface morphology or cellular architecture examined by scanning and transmission electron microscopy, respectively. We conclude that loss of anxA4 from the urothelium does not affect barrier function, membrane trafficking, or normal bladder-voiding behavior.

Disaster preparedness: when your community needs you most.

When disaster strikes, the community first turns to its local hospital for help. Make sure your board and hospital leadership have thought through potential disaster scenarios and have a range of most-needed response plans in place.

Growing leaders in your own back yard.

In seeking future hospital leaders, follow two overarching guidelines: start developing them from within and make leadership training ongoing.

Care with compassion. The case for palliative care.

As the population ages, and complex, chronic conditions become more prevalent in the patient mix, hospitals need to take a sharper look at the advantages--and common sense--of palliative care.

Arresting death: saving 100,000 lives.

In January 2005, the Institute for Healthcare Improvement asked the nation's hospitals to voluntarily implement six specific care practices to prevent 100,000 unnecessary patient deaths by June 2006. Find out how they not only met, but exceeded, their goal.