TBI risk stratification at presentation: a prospective study of the incidence and timing of radiographic worsening in the Parkland Protocol.

BACKGROUND: We have created a theoretical algorithm for venous thromboembolism prophylaxis after traumatic brain injury (TBI) known as the Parkland Protocol, which stratifies patients into low-, medium-, and high-risk categories for spontaneous progression of hemorrhage. This prospective study characterizes the incidence and timing of radiographic progression of the TBI patterns in these categories. METHODS: Inclusion criterion was presentation with intracranial blood between February 2010 and March 2011; exclusion was receipt of only one computed tomographic scan of the head during the inpatient stay or preinjury warfarin. At admission, all patients were preliminarily categorized per the Parkland Protocol as follows: low risk (LR), patients meeting the modified Berne-Norwood criteria; moderate risk (MR), injuries larger than the modified Berne-Norwood criteria without requiring a neurosurgical procedure; high risk (HR), any patient with a craniotomy/monitor. RESULTS: A total of 245 patients with intracranial hemorrhage were enrolled during the 13-month study period. Of patients preliminarily classified as LR at admission (n = 136), progression was seen in 25.0%. Spontaneous worsening was seen in 7.4% of LR patients at 24 hours after injury, and no LR patients progressed at 72 hours after injury. In patients initially classified as MR at admission (n = 42), progression was seen in 42.9%, with 91.5% of patients demonstrating stable computed tomographic head scans at 72 hours after injury. In patients initially classified as HR (n = 67), 64.2% demonstrated spontaneous progression of their TBI patterns, with 10.5% continuing to progress at 72 hours after injury. Most repeat scans were performed as routinely scheduled studies (81-91%). CONCLUSION: Increases in the incidence of spontaneous worsening were seen as severities of injury progressed from the Parkland Protocol's LR to MR to HR arms. The time frames for these spontaneous worsenings seem to be such that the protocol's theoretical recommendations for venous thromboembolism prophylaxis are worth pursuing as future points of investigation.

Salvage of angioplasty failures and complications in hemodialysis arteriovenous access using the FLUENCY Plus Stent Graft: technical and 180-day patency results.

PURPOSE: To review technical and 180-day clinical outcomes when stent grafts were used to treat dysfunctional arteriovenous (AV) hemodialysis access circuits. MATERIALS AND METHODS: The FLUENCY Plus Stent Graft (Bard Peripheral Vascular, Tempe, Arizona) was used to salvage percutaneous transluminal angioplasty (PTA) technical failures and complications in AV access circuits over 2 years. There were 106 patients treated with 138 stent grafts. Indications for stent graft use included residual stenosis after PTA (n = 81), extravasation after PTA (n = 22), early recurrent stenosis (n = 14), pseudoaneurysms (n = 4), and "other" (n = 4). Data were retrospectively analyzed for complications and outcomes. RESULTS: Technical success was achieved in all patients, and clinical success was achieved in 104 (98%) of 106 patients. At 180 days, postintervention primary patency (PIPP) was 47%, and postintervention secondary patency (PISP) was 79%. PIPP was 62% for autogenous fistulas (AVFs) and 35% for prosthetic grafts (AVGs) (P = .010). The 180-day PIPP for stent grafts 9-10 mm in diameter was 63% versus 38% for stent grafts 6-8 mm in diameter (P = .012). Implants that did not cross the elbow had a 180-day PIPP of 47% compared with 25% for implants across the elbow (P = .032). Technical complications were periprocedure AVG thromboses (n = 2), intraprocedural stent graft dislodgment (n = 1), venospasm (n = 2), and contrast agent-related hives (n = 1). One patient returned at 2 months with an infected AVG and stent graft in the outflow vein. CONCLUSIONS: The FLUENCY Plus Stent Graft was effective for maintenance of hemodialysis access circuit patency and was comparable or better than historical outcomes for PTA and bare stents. Factors that favored improved patency included larger diameter devices, use in AVFs, and avoiding placement across the elbow joint.

First episode of major depressive disorder and vascular factors in coronary artery disease patients: Baseline characteristics and response to antidepressant treatment in the CREATE trial.

OBJECTIVE: The CREATE trial reported that coronary artery disease (CAD) patients suffering from a first depression derived less benefit from citalopram relative to placebo than those with a recurrent depression. The present investigation sought to determine whether the differential benefit of citalopram between those with a first depression and those with recurrent depression could be explained by indicators of vascular depression and cardiac disease severity. METHODS: Secondary analyses of data from CREATE, a 12-week, randomized placebo-controlled trial of 284 patients with major depressive disorder and CAD were used. Recurrence subgroups were compared on baseline characteristics reflecting vascular depression and cardiac disease severity. Outcome measures were the mean change from baseline to 12 weeks on the 24-item Hamilton Depression Rating Scale administered centrally by telephone. ANCOVA was used to assess the potential interaction of each baseline variable with citalopram/placebo treatment in predicting outcomes. RESULTS: Few baseline differences differentiated patients with a first versus recurrent depression, and none accounted for the differential treatment efficacy in these subgroups. Patients with a cardiac event in the past 6 months (P=.02) and taking angiotensin-converting enzyme inhibitors (P=.03) experienced less change with citalopram relative to placebo. Older age, worse functional status, taking beta-blockers, presence of angina (all P<.05), and later age of first depression (P=.05) predicted smaller changes in depression, independent of treatment assignment. CONCLUSIONS: There was limited evidence that the lack of improvement with citalopram relative to placebo in CAD patients with a first depression can be attributed to vascular depression.

Accuracy of stepping-table lower extremity MR angiography with dual-level bolus timing and separate calf acquisition: hybrid peripheral MR angiography.

PURPOSE: To retrospectively evaluate the accuracy of hybrid peripheral magnetic resonance (MR) angiography by using conventional digital subtraction angiography (DSA) as the reference standard. MATERIALS AND METHODS: This retrospective study protocol received approval from the Office of Sponsored Research at Northwestern University, which included review by the Office for the Protection of Research Subjects. Informed consent was waived for this HIPAA-compliant study. One hundred twenty-one consecutive patients (67 men: mean age, 66 years +/- 12 [standard deviation]; 54 women: mean age, 69 years +/- 14), who were referred for evaluation of peripheral vascular disease, underwent peripheral contrast material-enhanced MR angiography. By using a hybrid technique, two independent timing measurements were performed in the pelvis and calves followed by MR angiography of the calves and, subsequently, a pelvis-thigh stepping-table acquisition. Images were evaluated for extent of disease, on the basis of degree of stenosis; for venous contamination, on the basis of venous signal intensity; and for diagnostic quality, on the basis of diagnostic confidence of the observer. DSA correlation of the extent of vascular disease was available in 45 of these patients, which was used to evaluate the diagnostic power of the hybrid technique. RESULTS: For detection of stenosis greater than 50%, the hybrid technique had 95% sensitivity (P < .05), 95% specificity (P < .05), and 95% accuracy (P < .05). There was no significant venous contamination in any of the examinations performed with this technique. CONCLUSION: The hybrid peripheral MR angiography technique provides diagnostic-quality examinations and virtually eliminates venous contamination.

The relationship of quality of life, depression, and caregiver burden in outpatients with congestive heart failure.

Primary caregivers of patients with congestive heart failure withstand enormous burden, often sacrificing their own quality of life. The relationship between caregiver burden and depression and patient quality of life and depression in this setting is unknown. Fifty outpatients were prospectively administered the Minnesota Living with Heart Failure Questionnaire and Beck Depression Inventory II (BDI-II). Caregivers were administered the Zarit Caregiver Burden Interview and BDI-II. The mean quality of life score was 35, and 26% had a BDI-II score >10. The mean Zarit Caregiver Burden Interview score was 16. Minnesota Living with Heart Failure Questionnaire, BDI-II, and Zarit Caregiver Burden Interview scores were all associated with lower ejection fraction, need for hospitalization, increased number of medications, and comorbidities. Patient Minnesota Living with Heart Failure Questionnaire score correlated with patient BDI-II, caregiver BDI-II, and Zarit Caregiver Burden Interview scores. Caregiver burden score correlated with both caregiver BDI-II and patient BDI-II. Death or hospitalization at 6 months was associated with caregiver burden and depressive symptoms and with patient quality of life and depressive symptoms. Caregivers of patients with congestive heart failure experience high caregiver burden and prevalence of depressive symptoms, which are related to the patient disease burden.