Xenografts and Tissue Engineered Heart Valve in Pediatric Cardiac Surgery. Quo Vadis, Once More?

Introduction: Many attempts have been undertaken for surgical correction of congenital heart defects. Reconstruction of the right ventricular outflow tract (RVOT) is a main component of many procedures. Homograft devices are considered as benchmark, but these are in short supply. Xenografts and tissue engineered heart valves (TEHV) have been proposed as solution. This review aims to explore what progress has been made for these two alternatives.Methods: A systematic search for TEHV and the commonly used xenograft (Matrix P / P+, Shelhigh and Contegra) devices through ISI web of Knowledge was performed. The SynerGraft homograft was also included.Results: Contegra, Shelhigh and Matrix P / Matrix P+ have been used with varying success. The problems are foreign body reaction, with inflammation, stenosis of the conduit or more distally in the pulmonary arteries and regurgitation. In spite of efforts during more than 20 years, TEHV has not left the laboratory: there is still an ongoing search for the ideal scaffold, adequate cell sources for cellular repopulation and culture media. There are no long-term animal models for the latter device.Conclusions: To treat patients with congenital heart disease, reconstruction can be performed with xenograft devices, but their limitations have to be taken into account. Matrix P and P+ as well as Shelhigh suffer from inflammation with stenosis. The alternative, TEHV, will not be available for the foreseeable future. In any case, any TEHV device has to compete against more established values

Heart Failure after Aortic Valve Replacement for Aortic Valve Stenosis: Possible Mechanisms

Introduction: Aortic valve stenosis imposes a pressure overload on the left ventricle. Congestive heart failure is one of the complications which can appear, even years after the operation. The main questions are: why do patients still develop heart failure? Which types of congestive heart failure can be expected? Which factors related to it are known?Methods: A literature search was performed with the terms “aortic valve disease/replacement AND heart failureâ€. Some secondary references derived from their reference list were also included. The study design of the selected papers differed considerably. Therefore, the analysis is descriptive and concerns factors which can be related to congestive heart failure. Furthermore, surrogate outcomes are ejection fraction, hypertrophy, long axis ventricular function, torsion, left atrial indices, pressures in the left sided heart and in the pulmonary circulation as well as a number of other echocardiographic parameters.Results: It has become clear that decrease in ejection fraction, which is the most commonly used parameter, occurs late in the course of aortic valve stenosis, when damage to the left ventricle has already been inflicted. Several more sensitive imaging and Doppler parameters can demonstrate these changes earlier in the course of aortic valve stenosis. This damage proves to be irreversible, at least in part. This might explain the appearance of heart failure after aortic valve replacement. Although this type of heart failure is mostly “diastolic†in nature, a continuum with the systolic type probably exists, at least in patients with aortic valve stenosis.Conclusions: Damage to the left ventricle in patients with aortic valve stenosis can go unnoticed if ejection fraction is used as sole determinant of left ventricular function, for the timing of operation. Detection of more subtle changes, even in asymptomatic patients with severe aortic valve stenosis should lead to early replacement. This might result in less postoperative heart failure

What is the Advantage of using Risk Score in Infective Endocarditis: An Opinion

Infectious endocarditis (IE) is a very heterogeneous condition, which often requires surgical treatment. Even with surgical treatment, 30-day mortality rate can be high. A risk stratification is needed for the individual prognosis of the patient, but also for quality of care. Existing scores such as EuroSCORE II and STS scores do not include specific IE related parameters and give a poor assessment of the prognosis.A literature search was made in Web of Science for existing risk scores. The use of secondary references from comparative series proved to be necessary.Eight useful manuscripts could be identified in which a model was constructed. Two more comparative manuscripts are also found. Regression coefficients were mostly used to achieve this aim. However, there is considerable variation in study design, inclusion of patients and of risk factors. Definitions of risk factors and length of inclusion also vary. Five factors are of major importance: hemodynamic status, renal dysfunction, age, prosthetic valve infection and periannular involvement. In only one report medically treated patients are included which allows inclusion surgery itself as a factor.Hemodynamic status (including heart failure and need for mechanical support), renal dysfunction and age prove in most instances to be the dominant factors, but more specific IE related factors such as microbial data, Periannular involvement and cardiac damage should not be neglected. Because of the lengthy inclusion time, improvement of operative and postoperative care should be taken into consideration. These models have a potential value, but continuous recalibration, based on future international prospective data collection (such as in ICE-PCS) is necessary

Statins and Malignancies in Cardiovascular Practice

Statins have a proven efficacy in lowering of plasma cholesterol and reduction of atherosclerotic cardiovascular disease. They also have anti-inflammatory, pro-apoptotic and anti-angiogenic effects which can be derived from their biochemical activity. The cell cycle could also be arrested at several stages. However, an early concern was the possibility of increase in malignancy. The first reports were conflicting.A search in Web of Science has been made with the terms “statins AND malignancyâ€, from 2012 to 2017.Twenty of 119 manuscripts were considered as useful. Manuscripts dealing with in-vitro and animal experiments were excluded, as well as reviews and manuscripts not related to the topic. There was a variety of malignancies under scrutiny. Most series showed a favorable result on either reduction of incidence in malignancy or, if a malignancy was diagnosed and improvement in overall or cancer specific survival. Reduction in symptoms and improvement in inflammatory response after adjuvant chemo and radiotherapy were documented in a few reports.Elimination of bias has been attempted by taking into account confounding factors or by using a propensity analysis or a multivariate regression. Interpreting these results is difficult due to the differences in study designs. This precluded a meta-analysis. The disentangling of the effect of statins on malignancy, plasma cholesterol and changes of this level in these patients requires a large multicenter prospective trial which might encounter ethical and logistical difficulties

Scintigraphic Evaluation of Endocarditis

Introduction: Infective endocarditis (IE) is a very heterogeneous condition for several reasons. The diagnosis can be notoriously difficult. A delay in diagnosis can have severe consequences. Even proper application of the Duke criteria cannot solve all cases. For this reason, positron emission tomography / computer tomography (PET/CT) with 18F-fluorodesoxyglucose (18FDG) has been proposed in the 2015 guidelines of the European Society of Cardiology. What has been the effect of these guidelines thus far?Methods: A probe of the literature has been performed in PubMed, from 2016 on using the search terms “endocarditis AND PETâ€Results: One hundred items were identified, of which 41 documents could be retained. However, only 16 were original series, mostly with low numbers. The other manuscripts were editorials, comments, reviews and “image vignettesâ€. PET/CT increased the sensitivity of the Duke criteria in cases of prosthetic valve endocarditis (PVE), but in a much lesser degree in native valve endocarditis (NVE). Patient preparation should be standardized in order to reduce the uptake of 18FDG by the myocardium. This includes low carbohydrate – high fat diet, fasting and unfractionated heparin administration. Furthermore, image acquisition and processing (quantification, correction for attenuation, taking into account implanted metallic materials) should also be standardized. Effects of antibiotics (negative imaging results before cure) and inflammation (especially healing after operation and use of biological glue materials) should be taken into account. Radiolabeled white blood cell scintigraphy could be a valuable adjunct in these cases. The detection of extra-cardiac foci (especially tumors which can serve as port of entry and septic emboli) is an additional advantage.Conclusion: PET/CT seems a valuable tool to increase the accuracy in diagnosing IE, especially PVE. Early postoperative cases must be interpreted with caution. To confirm the value of PET/CT, the major centers should standardize their method. This allows comparison of results of larger patient groups, which could be collected in the International Collaboration of Endocarditis – Prospective Cohort Study. Nuclear cardiologists should also be included in “endocarditis teams

A multilevel analysis of three randomised controlled trials of the Australian Medical Sheepskin in the prevention of sacral pressure ulcers

Objective: To assess the effectiveness of the Australian Medical Sheepskin in preventing sacral pressure ulcers (PUs), based on combined data from existing published trials. Design and setting: Data from two randomised controlled trials (RCTs) among Australian hospital patients and one RCT among Dutch nursing home patients were pooled, comprising a total population of 1281 patients from 45 nursing wards in 11 institutions. These data were analysed in two ways: with conventional meta-analysis based on the published effect sizes; and with multilevel binary logistic regression based on the combined individual patient data. In the multilevel analysis, patient, nursing ward and institution were used as levels and we controlled for sex, age, PU risk and number of days of observation.Main outcome measure: Incidence of sacral PUs. Results: Overall, the incidence of sacral PUs was 12.2% in the control group versus 5.4% in the intervention group with an Australian Medical Sheepskin. Conventional meta-analysis showed significantly reduced odds of developing a PU while using the sheepskin (odds ratio [OR], 0.37 [95% CI, 0.17–0.77]). Multilevel analysis gave an OR of 0.35 and narrowed the confidence interval by almost 50% (95% CI, 0.23–0.55). Conclusions: These analyses of pooled data confirm that the Australian Medical Sheepskin is effective in preventing sacral PUs. Multilevel analysis of individual patient data gives a more precise effect estimate than conventional meta-analysis

An economic appraisal of the Australian Medical Sheepskin for the prevention of sacral pressure ulcers from a nursing home perspective

<p>Abstract</p> <p>Background</p> <p>Many devices are in use to prevent pressure ulcers, but from most little is known about their effects and costs. One such preventive device is the Australian Medical Sheepskin that has been proven effective in three randomized trials. In this study the costs and savings from the use of the Australian Medical Sheepskin were investigated from the perspective of a nursing home.</p> <p>Methods</p> <p>An economic model was developed in which monetary costs and monetary savings in respect of the sheepskin were balanced against each other. The model was applied to a fictional (Dutch) nursing home with 100 beds for rehabilitation patients and a time horizon of one year. Input variables for the model consisted of investment costs for using the sheepskin (purchase and laundry), and savings through the prevented cases of pressure ulcers. The input values for the investment costs and for the effectiveness were empirically based on a trial with newly admitted rehabilitation patients from eight nursing homes. The input values for the costs of pressure ulcer treatment were estimated by means of four different approaches.</p> <p>Results</p> <p>Investment costs for using the Australian Medical Sheepskin were larger than the monetary savings obtained by preventing pressure ulcers. Use of the Australian Medical Sheepskin involves an additional cost of approximately €2 per patient per day. Preventing one case of a sacral pressure ulcer by means of the Australian Medical Sheepskin involves an investment of €2,974 when the sheepskin is given to all patients. When the sheepskin is selectively used for more critical patients only, the investment to prevent one case of sacral pressure ulcers decreases to €2,479 (pressure ulcer risk patients) or €1,847 (ADL-severely impaired patients). The factors with the strongest influence on the balance are the frequency of changing the sheepskin and the costs of washing related to this. The economic model was hampered by considerable uncertainty in the estimations of the costs of pressure ulcer treatment.</p> <p>Conclusions</p> <p>From a nursing home perspective, the investment costs for use of the Australian Medical Sheepskin in newly admitted rehabilitation patients are larger than the monetary savings obtained by preventing pressure ulcers.</p

Telephone follow-up of patients after radical prostatectomy : a systematic review

Objective: to assess and summarize the best scientific evidence from randomized controlled clinical trials about telephone follow-up of patients after radical prostatectomy, based on information about how the phone calls are made and the clinical and psychological effects for the individuals who received this intervention. Method: the search was undertaken in the electronic databases Medline, Web of Science, Embase, Cinahl, Lilacs and Cochrane. Among the 368 references found, five were selected. Results: two studies tested interventions focused on psychological support and three tested interventions focused on the physical effects of treatment. The psychoeducative intervention to manage the uncertainty about the disease and the treatment revealed statistically significant evidences and reduced the level of uncertainty and anguish it causes. Conclusion: the beneficial effects of telephone follow-up could be determined, as a useful tool for the monitoring of post-prostatectomy patients.Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

A predictive score to identify hospitalized patients' risk of discharge to a post-acute care facility

<p>Abstract</p> <p>Background</p> <p>Early identification of patients who need post-acute care (PAC) may improve discharge planning. The purposes of the study were to develop and validate a score predicting discharge to a post-acute care (PAC) facility and to determine its best assessment time.</p> <p>Methods</p> <p>We conducted a prospective study including 349 (derivation cohort) and 161 (validation cohort) consecutive patients in a general internal medicine service of a teaching hospital. We developed logistic regression models predicting discharge to a PAC facility, based on patient variables measured on admission (day 1) and on day 3. The value of each model was assessed by its area under the receiver operating characteristics curve (AUC). A simple numerical score was derived from the best model, and was validated in a separate cohort.</p> <p>Results</p> <p>Prediction of discharge to a PAC facility was as accurate on day 1 (AUC: 0.81) as on day 3 (AUC: 0.82). The day-3 model was more parsimonious, with 5 variables: patient's partner inability to provide home help (4 pts); inability to self-manage drug regimen (4 pts); number of active medical problems on admission (1 pt per problem); dependency in bathing (4 pts) and in transfers from bed to chair (4 pts) on day 3. A score ≥ 8 points predicted discharge to a PAC facility with a sensitivity of 87% and a specificity of 63%, and was significantly associated with inappropriate hospital days due to discharge delays. Internal and external validations confirmed these results.</p> <p>Conclusion</p> <p>A simple score computed on the 3rd hospital day predicted discharge to a PAC facility with good accuracy. A score > 8 points should prompt early discharge planning.</p

Tailored education for older patients to facilitate engagement in falls prevention strategies after hospital discharge—A pilot randomized controlled trial

Background The aims of the study were to evaluate the effect of providing tailored falls prevention education in hospital on: i) engagement in targeted falls prevention behaviors in the month after discharge: ii) patients’ self-perceived risk and knowledge about falls and falls prevention strategies after receiving the education. Methods A pilot randomized controlled trial (n = 50): baseline and outcome assessments conducted by blinded researchers. Participants: hospital inpatients 60 years or older, discharged to the community. Participants were randomized into two groups. The intervention was a tailored education package consisting of multimedia falls prevention information with trained health professional follow-up, delivered in addition to usual care. Outcome measures were engagement in falls prevention behaviors in the month after discharge measured at one month after discharge with a structured survey, and participants’ knowledge, confidence and motivation levels before and after receiving the education. The feasibility of providing the intervention was examined and falls outcomes (falls, fall-related injuries) were also collected. Results Forty-eight patients (98%) provided follow-up data. The complete package was provided to 21 (84%) intervention group participants. Participants in the intervention group were significantly more likely to plan how to safely restart functional activities [Adjusted odds ratio 3.80, 95% CI (1.07, 13.52), p = 0.04] and more likely to complete other targeted behaviors such as completing their own home exercise program [Adjusted odds ratio 2.76, 95% CI (0.72, 10.50), p = 0.14] than the control group. The intervention group was significantly more knowledgeable, confident and motivated to engage in falls prevention strategies after receiving the education than the control group. There were 23 falls (n = 5 intervention; n = 18 control) and falls rates were 5.4/1000 patient days (intervention); 18.7/1000 patient days (control). Conclusion This tailored education was received positively by older people, resulted in increased engagement in falls prevention strategies after discharge and is feasible to deliver to older hospital patients. Trial registration The study was registered with the Australian New Zealand Clinical Trials Registry; ACTRN12611000963921 on 8th November 2011