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Regional ventilation-perfusion changes after endobronchial valve therapy assessed by single-photon emission computed tomography in adults with severe COPD
No full textBronchoscopic lung volume reduction (BLVR) is an established treatment for patients with severe chronic obstructive pulmonary disease (COPD), characterized as emphysema and hyperinflation, but current methods of patient selection and lobe identification are limited due to invasiveness, lack of specificity, and poor regional ventilation and perfusion assessments. This study aimed to evaluate lobar changes in ventilation, perfusion, and volume before and after endobronchial valve (EBV) placement using SPECT/CT imaging in patients with severe emphysema, and to assess their association with clinical outcomes. A prospective, single-center, pilot study enrolled six patients with severe COPD (FEV
≤ 50%), and hyperinflation on pulmonary function tests (PFTs). Additionally, participants had severe heterogeneous emphysema (≥ 70% with voxel density ≤ - 910 Hounsfield units), and adequate fissure integrity (≥ 95%), both quantified by StratX™. All participants underwent BLVR in a single target lobe and received pre- and post-procedure SPECT/CT imaging using nebulized
Tc inhaled in the upright position to assess ventilation followed by
Tc-macroaggregated albumin injection to assess perfusion. Ventilation, perfusion, and volume were quantified at the target, adjacent, and contralateral lobes using AutoLung 3D software. PFTs and six-minute walk tests (6MWT) were obtained before and after BLVR. Treated lobes demonstrated a significant reduction in ventilation (66.7% [IQR 47.1-88.2]), perfusion (71.9% [63.1-78.8]), and volume (26.2% [10.4-35.3]) after BLVR. Adjacent lobes exhibited compensatory increases in ventilation (16.7% [8.5-51.3]), perfusion (+ 22.9% [19.7-33.9]), and volume (+ 12.6% [8.0-17.4]), while changes in contralateral lobes were minimal. These physiological changes weakly correlated with FEV
and 6MWT, which may suggest a disconnect between regional physiological adaptation and functional capacity. While prior studies have evaluated baseline physiology with SPECT/CT prior to BLVR, this is the first study to use this novel imaging to assess physiological responses after BLVR. SPECT/CT is a promising tool for evaluating lobar-level physiological responses to BLVR. Larger, multicenter studies with long-term follow-up are needed to validate its utility in patient selection, procedural planning, and outcome prediction following BLVR
Conventional versus advanced imaging selection for endovascular treatment of basilar artery occlusion strokes
No full textIntroduction Endovascular thrombectomy (EVT) is an effective treatment for basilar artery occlusion (BAO) stroke in select patients. While there is a growing body of literature suggesting that advanced imaging modalities such as computed tomography perfusion (CTP) and magnetic resonance (MR) may not be necessary for selecting anterior circulation large vessel occlusion stroke patients for EVT, whether advanced imaging may be superior to conventional imaging (non-contrast CT and CT angiography) in identifying good treatment candidates among BAO patients is less clear. Patients and methods This was a multicenter retrospective cohort study of BAO EVT patients treated from 2013 to 2022 in the Stroke Thrombectomy and Aneurysm Registry. Patients selected for EVT by advanced imaging (CTP or MR) were matched with those selected by conventional imaging using propensity score matching (PSM) accounting for possible confounders. Primary outcome was functional independence at 90 days. Other outcomes include bedridden state or death at 90-days and symptomatic intracranial hemorrhage (sICH). Results 268 patients were included. 150 patients were selected for BAO EVT by conventional imaging, 86 by CTP, and 32 by MR. Patients selected by advanced imaging were significantly older than those selected by conventional imaging (median age 71 vs 64 years, p = 0.001); patient characteristics were otherwise similar between cohorts. After PSM, 90-day outcomes were similar between the two cohorts (p = 0.56), with similar rates of functional independence (39.4% vs 35.1%, p = 0.65), bedridden state or death (40.4% vs 44.7%, p = 0.66), and sICH (3.3% vs 5.7%, p = 0.49) for conventional and advanced imaging groups, respectively. Results were similar across treatment time windows (all p > 0.05). Conclusions Selecting patients for basilar EVT using conventional versus advanced imaging did not result in different clinical outcomes, regardless of treatment time windows. Conventional imaging appears sufficient as a first-line tool for selecting basilar EVT patients in routine clinical practice
Laminoplasty Versus Laminectomy and Fusion in the Treatment of Degenerative Cervical Myelopathy: A Systematic Review and Meta-Analysis of Cost and Patient-Centered Outcomes in the United States
No full textStudy designSystematic review and meta-analysis.ObjectiveThis systematic review and meta-analysis compared cervical laminoplasty (LP) with laminectomy and fusion (LF) for the treatment of degenerative cervical myelopathy (DCM), focusing on healthcare costs and patient-centered outcomes.MethodsA systematic review of EMBASE and Medline (inception to September 2024) identified studies comparing LP and LF for multilevel DCM. Outcomes included return-to-work (RTW), direct treatment costs, and changes in pain and opioid use. Meta-analyses were performed using random-effects models to estimate pooled mean differences (MD) between treatment arms and mean per treatment for study outcomes. Study quality was assessed with the Newcastle-Ottawa Scale.ResultsTwelve retrospective cohort studies (7581 patients; LP: 1,848, LF: 5733) met inclusion criteria. After appraising the included studies, we determined that 25% were of high quality, 67% were of moderate quality, and 8% were of low quality. LF had higher treatment costs (29,503.72-52,109.07 USD, 95% CI 91,985.43), with an MD of -35,215 to -$8025.53, I
= 95%). LF led to greater pain reduction (MD in VAS = 1.60, 95% CI 0.36-2.84, I
= 63%). Opioid use was inconsistently reported, preventing meta-analysis. One study found higher RTW rates at 12 months for LP (88.9%) vs LF (64.3%).ConclusionLF incurred greater costs but provided superior pain relief. Significant heterogeneity and limited high-quality evidence highlight the need for further research on cost-effectiveness and patient-centered outcomes
Preserved Adrenal Function After Left Renal Cell Carcinoma With Tumor Thrombus Resection and Right Adrenal Vein Ligation: A Case Report
No full textAdrenal insufficiency is a recognized complication following adrenalectomy and, less commonly, nephrectomy due to the anatomical and functional relationship between the adrenal glands and kidneys. While unilateral adrenalectomy is typically well tolerated due to compensation by the contralateral adrenal gland, adrenal insufficiency may still occur, particularly in cases involving bilateral disease. Recognizing and managing this risk is critical in postoperative care to prevent life-threatening adrenal crises.
We present a case of left renal cell carcinoma (RCC) with tumor thrombus (TT) level IV (extending into the right atrium). The surgery was completed exclusively through an abdominal approach without cardiopulmonary bypass (CPB). The surgical approach involved a left radical nephrectomy, left adrenalectomy, and removal of a large TT, which included a segment of the inferior vena cava (IVC) and the right adrenal vein. As a result, the right adrenal vein was sacrificed, and adrenal insufficiency was expected due to ligation of the right adrenal vein and removal of the left adrenal gland. However, one year after the procedure, adrenal insufficiency was not seen, perhaps due to venous collaterals draining the right adrenal gland.
This case highlights that in the case of complete obstruction of the IVC by the TT of an RCC, the remaining adrenal vein can be sacrificed without causing adrenal insufficiency, perhaps due to the presence of multiple venous collaterals that developed from chronic obstruction of the IVC
Exploring patient-initiated communication after nail procedures: a single-center retrospective study
No full textCare Ethics and Beyond
No full textCare ethics does very well on its own, but we can give it a larger justificatory context by subsuming it under Chinese yin and yang, understood, respectively, as receptivity and active purposefulness. Caring involves both empathy and helpfulness, and empathy is a form of receptivity, helpfulness of active purposefulness. But yin and yang can also help us understand practically rational prudence and the two basic building blocks of the mind: belief and desire. So care ethics can receive further support by showing how it can form part of a larger yin/yang philosophy that the present chapter offers an extended argument for
Evaluating the Baby Steps Model: Reflection on Practice Implications
No full textLaunched in 2020, the Baby Steps model and program supports infants discharged from the neonatal intensive care unit (NICU) and their caregivers during the transition to home. This single-site 5-year evaluation examined program engagement, 30-day readmissions, and emergency department and urgent care utilization. Demographic and outcome data were summarized descriptively. Among 808 families, 76% received Baby Steps services and 38% utilized telehealth. 30-day readmissions declined compared with pre-implementation rates; care utilization varied by year. The Baby Steps model and program has provided sustained support resulting in clinical outcome improvements after NICU discharge, despite implementation challenges.
•The nurse-led Baby Steps program supported more than 800 NICU families after discharge.•Program outcomes include a reduction in 30-day readmission rates.•Shifts in telehealth encounters may reflect evolving family care preferences.•Program sustainability depends on workforce support and hospital resources
Hepatic artery pseudoaneurysms: Two cases, 2 novel solutions, and a brief review of current treatments
No full textDespite their rarity, hepatic artery pseudoaneurysms present a major risk to patients associated with high mortality. Effective, timely treatment is crucial. Options include percutaneous, endovascular, and surgical management. The first case involved a 68-year-old female with a fusiform pseudoaneurysm at the bifurcation of the common hepatic into the proper hepatic artery and the gastroduodenal arteries. Onyx (ev3,Plymouth,MN) was used to reconstruct the vessel lumen while angiography confirmed embolization of the pseudoaneurysm and arterial patency. Postoperatively, the Hgb stabilized with discharge 5 days later. The second case involved a 45-year-old male with nausea, emesis, pain, elevated liver function tests, and a pseudoaneurysm of the proper hepatic artery seen on imaging. Balloon occlusion was performed for 50 minutes until complete thrombosis. This method was only feasible due to the dual blood supply of the liver. Postoperatively, the abdominal pain immediately resolved and liver enzymes returned to baseline with discharge 2 days later. Being both rare and deadly, effective treatments of hepatic artery pseudoaneurysms are necessary, but novel treatments are seldom documented. Here 2 cases are described: vessel reconstruction with Onyx and Prolonged Balloon Occlusion. Both proved to be effective. Future studies should investigate additional options
To pack or plug: American Association for the Surgery of Trauma multicenter evaluation of hemorrhage control interventions in pelvic fracture management
No full textMortality from pelvic ring fractures (PRFs) complicated by hemorrhagic shock remains high, and there are limited high-quality data to guide care. We compared two primary hemorrhage control interventions: pelvic angiography +/- embolization (PAE) and preperitoneal pelvic packing (PPP), hypothesizing similar odds of death.INTRODUCTIONMortality from pelvic ring fractures (PRFs) complicated by hemorrhagic shock remains high, and there are limited high-quality data to guide care. We compared two primary hemorrhage control interventions: pelvic angiography +/- embolization (PAE) and preperitoneal pelvic packing (PPP), hypothesizing similar odds of death.A prospective, multicenter, observational study was conducted for individuals with blunt trauma-associated PRF with a systolic blood pressure of <90 mm Hg who received ≥4 U of packed red blood cells within 24 hours and/or used a hemorrhage control intervention (2022-2024). Bivariate comparisons, multivariable regression controlling for several clinical factors, and inverse probability treatment weighting analysis were performed. Primary outcomes were 3- and 6-hour mortality.METHODSA prospective, multicenter, observational study was conducted for individuals with blunt trauma-associated PRF with a systolic blood pressure of <90 mm Hg who received ≥4 U of packed red blood cells within 24 hours and/or used a hemorrhage control intervention (2022-2024). Bivariate comparisons, multivariable regression controlling for several clinical factors, and inverse probability treatment weighting analysis were performed. Primary outcomes were 3- and 6-hour mortality.Of 948 patients, 524 underwent either PPP (n = 68, 13.0%), PAE (n = 390, 74.4%), or both (n = 66, 12.6%) and comprise the study cohort. Compared with PAE, PPP patients had higher Injury Severity Scores (41 vs. 34, p < 0.001) and worse physiology (lowest systolic blood pressure, 62 vs. 74 mm Hg; lactate, 6.4 vs. 4.3; p < 0.001) and more frequently underwent laparotomy (67.6% vs. 23.6%, p < 0.001). In-hospital (47.1% vs. 18.5%, p < 0.001) and 24-hour (38.2% vs. 4.1%, p < 0.001) mortality were higher in PPP versus PAE with more earlier deaths (27.9% vs. 0.5% within 3 hours, p < 0.001). Preperitoneal pelvic packing was associated with higher odds of death at 3 hours (odds ratio, 64.0; confidence interval, 8.8-465.1) and 6 hours (odds ratio, 15.1; confidence interval, 4.4-51.7) compared with PAE. Inverse probability treatment weighting analysis demonstrated 19.4% higher probability of death at 6 hours for PPP versus PAE (p < 0.001).RESULTSOf 948 patients, 524 underwent either PPP (n = 68, 13.0%), PAE (n = 390, 74.4%), or both (n = 66, 12.6%) and comprise the study cohort. Compared with PAE, PPP patients had higher Injury Severity Scores (41 vs. 34, p < 0.001) and worse physiology (lowest systolic blood pressure, 62 vs. 74 mm Hg; lactate, 6.4 vs. 4.3; p < 0.001) and more frequently underwent laparotomy (67.6% vs. 23.6%, p < 0.001). In-hospital (47.1% vs. 18.5%, p < 0.001) and 24-hour (38.2% vs. 4.1%, p < 0.001) mortality were higher in PPP versus PAE with more earlier deaths (27.9% vs. 0.5% within 3 hours, p < 0.001). Preperitoneal pelvic packing was associated with higher odds of death at 3 hours (odds ratio, 64.0; confidence interval, 8.8-465.1) and 6 hours (odds ratio, 15.1; confidence interval, 4.4-51.7) compared with PAE. Inverse probability treatment weighting analysis demonstrated 19.4% higher probability of death at 6 hours for PPP versus PAE (p < 0.001).Whereas hypotensive patients with PRFs are more likely to undergo PAE, PPP is reserved for patients with more severe hemorrhagic shock, which may account for the observed higher mortality. Findings from this study suggest that PAE is an appropriate first-line therapy for most patients with bleeding pelvic fractures at trauma centers with rapid access to endovascular therapy.CONCLUSIONWhereas hypotensive patients with PRFs are more likely to undergo PAE, PPP is reserved for patients with more severe hemorrhagic shock, which may account for the observed higher mortality. Findings from this study suggest that PAE is an appropriate first-line therapy for most patients with bleeding pelvic fractures at trauma centers with rapid access to endovascular therapy.Therapeutic/Care Management; Level III.LEVEL OF EVIDENCETherapeutic/Care Management; Level III