Endotracheal instillation of prostacyclin in preterm infants with persistent pulmonary hypertension

Does endotracheal instilled prostacyclin (epoprostenol) improve oxygenation in preterm infants with persistent pulmonary hypertension? Four preterm infants were studied. Prostacyclin (50 ng x kg(-1)) was injected as an endotracheal bolus. In two patients the prostacyclin bolus was repeated and in one patient prostacyclin was administered continuously. Oxygenation was evaluated through the oxygenation index and the ratio of arterial oxygen tension to the fraction of inspired oxygen. The mean arterial blood pressure was used to evaluate systemic circulation. The oxygenation index (+/-SD) decreased significantly from 39 (+/-13.3) to 7 (+/-2.5) and the ratio of arterial oxygen tension to the fraction of inspired oxygen (+/-SD) increased significantly from 47 (+/-13) to 218 (+/-67), most likely related to a reduction of the pulmonary vascular resistance with a reversal of the extrapulmonary shunting at the ductus arteriosus and atrial level. The blood pressure did not change. All effects were reversed on drug withdrawal. Repeated or continuous endotracheal administration of prostacyclin in three children demonstrated a sustained response without tachyphylaxis, and without overt side-effects. Endotracheal instillation of prostacyclin resulted in an improved oxygenation without systemic vascular repercussions in four preterm infants with persistent pulmonary hypertension. Repeated or continuous administration showed a sustained response and no overt side-effects were noticed

High-frequency oscillatory ventilation is not superior to conventional mechanical ventilation in surfactant-treated rabbits with lung injury

The aim of this study was to compare high-frequency oscillatory ventilation (HFOV) with conventional mechanical ventilation (CMV) with and without surfactant in the treatment of surfactant-deficient rabbits. A previously described saline lung lavage model of lung injury in adult rabbits was used. The efficacy of each therapy was assessed by evaluating gas exchange, lung deflation stability and lung histopathology. Arterial oxygenation did not improve in the CMV group without surfactant but increased rapidly to prelavage values in the other three study groups. During deflation stability, arterial oxygenation decreased to postlavage values in the group that received HFOV alone, but not in both surfactant-treated groups (HFOV and CMV). The HFOV group without surfactant showed more cellular infiltration and epithelial damage compared with both surfactant-treated groups. There was no difference in gas exchange, lung deflation stability and lung injury between HFOV and CMV after surfactant therapy. It is concluded that the use of surfactant therapy in combination with high-frequency oscillatory ventilation is not superior to conventional mechanical ventilation in improving gas exchange, lung deflation stability and in the prevention of lung injury, if lungs are kept expanded. This indicates that achieving and maintaining alveolar expansion (i.e. open lung) is of more importance than the type of ventilator

Cost-effectiveness analysis for SilAtro-5-90 adjuvant treatment in the management of recurrent tonsillitis, compared with usual care only

Purpose: Antibiotics are one possible treatment for patients with recurrent acute throat infections (ATI), but effectiveness can be modest. In view of worries over antibiotic resistance, treatment pathways that reduce recurrence of ATI are essential from a public health perspective. Integrative treatment strategies can be an option but there is still a high demand to provide evidence of their cost effectiveness. Methods: We constructed a 4-state Markov model to compare the cost-effectiveness of SilAtro-5-90 as adjuvant homeopathic therapy to care as usual with care as usual alone in reducing the recurrence of ATI for children and adults with suspected moderate recurrent tonsillitis. The analysis was performed from a societal perspective in Germany over a 2-year period. Results are reported separately for children < 12 and for individuals aged 12 and over. The model draws on evidence from a multi-centre randomised clinical trial that found this strategy effective in reducing recurrence of ATI. Costs in 2019 € and outcomes after 1 year are discounted at a rate of 3% per annum. Results: For adults and adolescents aged 12 years and over, incremental cost per ATI averted in the adjuvant therapy group was €156.64. If individuals enter the model on average with a history of 3.33 previous ATIs, adjuvant therapy has both lower costs and better outcomes than care as usual. For children (< 12 years) adjuvant therapy had both lower costs and ATI than care as usual. The economic case is stronger if adjuvant treatment reduces surgical referral. At a hypothetical cost per ATI averted threshold of €1000 probabilistic sensitivity analysis suggests Silatro-5-90 has a 65% (adults) and 71% (children) chance of being cost-effective. Conclusion: Our results indicate the importance of considering homeopathy as adjuvant therapy in the treatment of ATIs in individuals with recurrent tonsillitis from a socio-economic perspective. Further evaluation should assess how differences in uptake and sustained use of homeopathic adjuvant therapy, as well as changing patterns of antibiotic prescribing, impact on cost effectiveness

Treatment decision for transcatheter aortic valve implantation: the role of the heart team: Position statement paper of the Dutch Working Group of Transcatheter Heart Interventions

The current paper presents a position statement of the Dutch Working Group of Transcatheter Heart Valve Interventions that describes which patients with aortic stenosis should be considered for transcatheter aortic valve implantation and how this treatment proposal/decision should be made. Given the complexity of the disease and the assessment of its severity, in particular in combination with the continuous emergence of new clinical insights and evidence from physiological and randomised clinical studies plus the introduction of novel innovative treatment modalities, the gatekeeper of the treatment proposal/decision and, thus, of qualification for cost reimbursement is the heart team, which consists of dedicated professionals working in specialised centres

Long-term follow-up of quality of life in high-risk patients undergoing transcatheter aortic valve implantation for symptomatic aortic valve stenosis

Background Transcatheter aortic valve implantation (TAVI) has become the standard treatment for patients with severe symptomatic aortic stenosis (AS) considered at very high risk for surgical aortic valve replacement. The purpose of this sub-study was to evaluate long-term (> 4 years) health-related quality of life (QoL) in octogenarians who underwent TAVI. Methods A single center observational registry in twenty patients who underwent frame analysis assessment = 4 years after TAVI. Health-related QoL was evaluated, using the Short Form-36 (SF-36), the EuroQoL-5D (EQ-5D) and the visual analogue score (EQ-VAS) questionnaires. Results The mean SF-36 subscale scores at follow-up were physical functioning 40.8 ± 26.3, role physical functioning 67.7 ± 34.9, vitality 54.6 ± 21.6, general health 52.1 ± 20.4, social functioning 63.8 ± 37.7, role emotional functioning 70.2 ± 36.0, mental health 73.2 ± 23.3 and bodily pain 80.9 ± 22.9. The mean EQ-VAS score > 4 years after TAVI was 64.7 ± 15.1. With respect to functional class, 80% of the patients were in NYHA class I/II at follow-up compared to 15% prior to TAVI. Conclusions This sub-study reports a significant improvement in functional class (NYHA) in a selected group of very elderly patients > 4 years after TAVI. Furthermore, all patients showed a satisfactory QoL despite their age and multiple comorbidities. In addition, our study reveals a lower QoL when compared with the general age matched Dutch population

Patients with aortic stenosis referred for TAVI: treatment decision, in-hospital outcome and determinants of survival

Aims To assess treatment decision and outcome in patients referred for transcatheter aortic valve implantation (TAVI) in addition to predictive factors of mortality after TAVI. Methods Three-centre prospective observational study including 358 patients. Endpoints were defined according to the Valve Academic Research Consortium. Results Of the 358 patients referred for TAVI, TAVI was performed in 235 patients (65%), surgical aortic valve replacement (AVR) in 24 (7%) and medical therapy (MT) in 99 (28%). Reasons to decline TAVI in favour of AVR/MT were patient preference (29%), peripheral vascular disease (15%) and non-severe aortic stenosis (11%). The logistic EuroSCORE was significantly higher in patients who underwent TAVI and MT in comparison with those undergoing AVR (19 vs. 10%, p=0.007). At 30 days, all-cause mortality and the combined safety endpoint were 9 and 24% after TAVI and 8 and 25% after AVR, respectively. All-cause mortality was significantly lower in the TAVI group compared with the MT group at 6 months, 1 year and 2 years (12% vs. 22%, 21% vs. 33% and 31% vs. 55%, respectively, p<0.001). Multivariable analysis revealed that blood transfusion (HR: 1.19; 95% CI: 1.05-1.33), pre-existing renal failure (HR: 1.18; 95% CI: 1.06-1.33) and STS score (HR: 1.06; 95% CI: 1.02-1.10) were independent predictors of mortality at a median of 10 (IQR: 3-23) months after TAVI. Conclusions Approximately two-thirds of the patients referred for TAVI receive this treatment with gratifying short- and long-term survival. Another 7% underwent AVR. Prognosis is poor in patients who do not receive valve replacement therapy