Association of Renin-Angiotensin-Aldosterone System Inhibitors With Clinical Outcomes, Hemodynamics, and Myocardial Remodeling Among Patients With Advanced Heart Failure on Left Ventricular Assist Device Support.

BACKGROUND: We evaluated the potential benefits of renin-angiotensin-aldosterone system inhibitors (RAASi) in patients with left ventricular assist device support. METHODS AND RESULTS: A total of 165 consecutive patients undergoing left ventricular assist device implant and alive at 6-month on support were studied. RAASi status after 6-month visit along with clinical reasons for nonprescription/uptitration were retrospectively assessed. The primary outcome was a composite of heart failure hospitalization or cardiovascular death between 6 and 24 months after left ventricular assist device implant. Remodeling and hemodynamic outcomes were explored by studying the association of RAASi new prescription/uptitration versus unmodified therapy at 6-month visit with the change in echocardiographic parameters and hemodynamics between 6 and 18 months. After the 6-month visit, 76% of patients were on RAASi. Patients' characteristics among those receiving and not receiving RAASi were mostly similar. Of 85 (52%) patients without RAASi new prescription/uptitration at 6-month visit, 62% had no apparent clinical reason. RAASi were independently associated with the primary outcome (adjusted hazard ratio, 0.31 [95% CI, 0.16-0.69]). The baseline rates of optimal echocardiographic profile (neutral interventricular septum, mitral regurgitation less than mild, and aortic valve opening) and hemodynamic profile (cardiac index ≥2.2 L/min per m2, wedge pressure <18 mm Hg, and right atrial pressure <12 mm Hg) were similar between groups. At 18 months, patients receiving RAASi new prescription/uptitration at 6 months had higher rates of optimal hemodynamic profile (57.5% versus 37.0%; P=0.032) and trends for higher rates of optimal echocardiographic profile (39.6% versus 22.9%; P=0.055) compared with patients with 6-month unmodified therapy. Optimal 18-month hemodynamic and echocardiographic profiles were associated with the primary outcome (log-rank=0.022 and log-rank=0.035, respectively). CONCLUSIONS: RAASi are associated with improved outcomes and improved hemodynamics among mechanically unloaded patients.

Videolaryngoscopy in neonatal clinical care.

Endotracheal intubation is a life-saving procedure for many newborns. Historically, it has been achieved by obtaining an airway view through the mouth via direct laryngoscopy. It is a skill that takes time and practice to achieve proficiency. Increasing evidence for the benefit of videolaryngoscopy in adults and the new development of technology has allowed videolaryngoscopy to become a reality in neonatal care. Studies have examined its use as both a technique to improve intubation safety and success, and as a training tool for those learning the skill in this vulnerable population. We present the current evidence for videolaryngoscopy in neonates in different settings where intubation may be required, in addition to exploring the challenges and practicalities of implementing this technique into clinical practice.

Is telemedicine suitable for remotely supporting non-tertiary units in providing emergency care to unwell newborns?

Although the majority of term infants will breathe spontaneously at birth, the requirement for advanced resuscitation can be unpredictable, as can the precipitous delivery of an extremely preterm infant in a non-tertiary neonatal unit. Infants born in hospitals without a tertiary neonatal intensive care unit have a higher mortality which is a disparity that has been difficult to resolve.Telemedicine, the use of videoconferencing software to connect those at the scene of a resuscitation to a remote clinician, can allow for real-time two-way communication between a local unit and a tertiary neonatal specialist. It has been present for some time in neonatology to provide secure video messaging with families and its use in neonatal acute care and resuscitation has been growing in recent years.We sought to perform a review of the current evidence available on the use of telemedicine in neonatal resuscitation. Studies demonstrate improved quality of resuscitation, improved adherence to resuscitation guidelines and positive experiences reported by local and tertiary teams. Suitable technology needs to be available to establish a rapid and secure video connection, as does adequate availability of experienced neonatologists to provide remote guidance. Telemedicine is an exciting and emerging tool which is being developed as a standard of care in units which have piloted it.

Isolation of Exophiala dermatitidis is not associated with worse clinical outcomes during acute pulmonary exacerbations in cystic fibrosis.

Introduction. The black yeast Exophiala dermatitidis has been isolated in respiratory samples from people with cystic fibrosis (CF). However, adequate detection may require longer incubation periods than the current UK national standard for CF respiratory samples. Furthermore, it is unclear whether isolation of E. dermatitidis is associated with poorer clinical outcomes in CF.Hypothesis/gap statement. E. dermatitidis does not cause clinically significant lung disease in CF adults.Aim. To evaluate differences in clinical outcomes over a 12 month period and during acute pulmonary exacerbations between CF adults with and without untreated E. dermatitidis.Methodology. Incubation times for respiratory samples on Sabouraud dextrose agar with chloramphenicol (SABC) plates at a large regional adult CF centre were extended from 2 to 7 days over a 1 month period. The number of patients from whom E. dermatitidis was isolated, and the length of incubation time prior to isolation, were recorded. Outcomes of treatment of exacerbations with intravenous antibiotics but in the absence of concomitant antifungal therapy were compared between those with and without E. dermatitidis, as were changes in lung function and body mass index (BMI) over a 12 month period.Results. Extended incubation unmasked the presence of E. dermatitidis in 22 of 132 patients; all isolations occurred after >48 h of incubation. Patients who isolated E. dermatitidis had lower rates of Pseudomonas aeruginosa isolation (P=0.02) and higher rates of non-tuberculous mycobacteria isolation (P=0.03), and were more likely to be prescribed a long-term antifungal medication (P=0.03), but had no differences in age, sex, baseline lung function or body mass index (BMI). There were no differences in response to treatment of acute exacerbations between patients with and without E. dermatitidis, or in change in forced expiratory volume in 1 s (FEV1), BMI and number of exacerbations over 12 months of follow-up.Conclusion. E. dermatitidis is not associated with worse clinical outcomes in CF. Given potential side effects and drug interactions, routine targeting of E. dermatitidis with antifungals during acute exacerbations is not advised.

Safe emergency neonatal airway management: current challenges and potential approaches.

This review examines the airway adjuncts currently used to acutely manage the neonatal airway. It describes the challenges encountered with facemask ventilation and intubation. Evidence is presented on how to optimise intubation safety and success rates with the use of videolaryngoscopy and attention to the intubation environment. The supraglottic airway (laryngeal mask airway) is emerging as a promising neonatal airway adjunct. It can be used effectively with little training to provide a viable alternative to facemask ventilation and intubation in neonatal resuscitation and be used as an alternative conduit for the administration of surfactant.

Implementation of a Standardized Neonatal Intubation Training Package.

OBJECTIVE: To assess the first attempt neonatal intubation success rates of pediatric trainees following the implementation of an evidence-based training package. STUDY DESIGN: Data collection was undertaken from February, 1 2017, to January 31, 2018, to ascertain baseline preimplementation intubation success rates. An intubation training package, which included the use of videolaryngoscopy, preprocedure pause, and standardized instruction during the procedure, was introduced. Data on all subsequent intubations were collected prospectively from May 1, 2018, to April 30, 2020. RESULTS: Preimplementation baseline data over a 1-year period demonstrated overall first attempt intubation success rate of junior trainees to be 37% (33/89). After implementation of the training package, 290 intubations were analyzed over a 2-year period. The overall success rate was 67% (194/290); 61% (117/192) for junior trainees and 79% (77/98) for senior clinicians. Three or more attempts were required for 13% of intubations (38/290). During the study period, the overall number of intubations being carried out decreased. Intubations with the videolaryngoscope had higher success rates for all tiers of clinician, most marked in the junior tiers. CONCLUSIONS: The introduction of a standardized intubation training package, along with videolaryngoscopy, improved trainee intubation success rates.

Minimally Invasive Left Ventricular Assist Device Implantation: A Comparative Study.

Left ventricular assist device (LVAD) is now a routine therapy for advanced heart failure. Minimally invasive approach via thoracotomy for LVAD implantation is getting popular due to its potential advantage over the conventional sternotomy approach in terms of reduced risk at re-operation due to sternal sparing. We compared the approaches (thoracotomy and sternotomy) to determine the superiority. Minimally invasive approach involved fitting of the LVAD inflow cannula into left ventricle apex via left anterior thoracotomy and anastomosis of outflow graft to ascending aorta via right anterior thoracotomy. In the sternotomy approach, both the procedures were performed via sternotomy. Outcomes in patients after LVAD implantation were compared depending on these approaches for the surgery. Two hundred and five continuous flow LVAD implantations performed between July 2006 and June 2015 at a single center were divided based on surgical approach, that is, sternotomy (n = 180) and thoracotomy (n = 25) groups. There was no significant difference between the groups in relation to patient demographics, preoperative hemodynamic parameters, laboratory markers, or risk factors. There was no significant difference between the groups in terms of postoperative hemodynamic parameters, laboratory markers, bleeding and requirement of blood products, intensive care unit, and hospital stay or complications of LVAD surgery. There were no significant differences in terms of long-term survival (Log-Rank P = 0.953), however, thoracotomy, compared to sternotomy approach, incurred significantly less requirement of temporary right ventricular assist (4 vs. 19.4%, P = 0.041). Minimally invasive bilateral thoracotomy approach for LVAD implantation in addition to benefits of sternal sparing avoids dilatation of right ventricle and reduces chances of right ventricular failure requiring temporary right ventricular assist.

Left ventricular assist device implantation with concomitant left ventricular reconstruction without patchplasty.

In this case report, we describe a 66-year-old patient with a massive LV aneurism which resulted after myocardial infarction. Due to severe LV function impairment, it was decided to perform left ventricular reconstruction surgery and, at the same time, left ventricular assist device implantation as a bridge to transplantation. The entire procedure was completed without using any patch material. The patient had an uneventful recovery and was discharged home after 18 days. After 1-year follow-up no adverse events were observed.

Isolation of outflow graft of a clotted ventricular assist device with recovery of cardiac function.

Ventricular assist device (VAD) thrombosis, though uncommon, is a well-known complication. A HeartWare VAD implanted 2 years ago in a middle-aged man stopped because of thrombosis in the VAD. Because the patient's left ventricular function was recovered by the time of intervention, only the outflow graft was isolated and cut, leaving the pump in place.

Accurate reading with sequential presentation of single letters.

Rapid, accurate reading is possible when isolated, single words from a sentence are sequentially presented at a fixed spatial location. We investigated if reading of words and sentences is possible when single letters are rapidly presented at the fovea under user-controlled or automatically controlled rates. When tested with complete sentences, trained participants achieved reading rates of over 60 wpm and accuracies of over 90% with the single letter reading (SLR) method and naive participants achieved average reading rates over 30 wpm with greater than 90% accuracy. Accuracy declined as individual letters were presented for shorter periods of time, even when the overall reading rate was maintained by increasing the duration of spaces between words. Words in the lexicon that occur more frequently were identified with higher accuracy and more quickly, demonstrating that trained participants have lexical access. In combination, our data strongly suggest that comprehension is possible and that SLR is a practicable form of reading under conditions in which normal scanning of text is not possible, or for scenarios with limited spatial and temporal resolution such as patients with low vision or prostheses.