Utilization of Shock Team and Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) in the Management of Cardiogenic Shock in Northern Ontario.

Background: Despite advancements in critical care and coronary revascularization, cardiogenic shock (CS) outcomes remain poor. Implementing a shock team and use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) have been associated with improved CS outcomes, but its feasibility in remote and rural areas remains unknown. Methods: This retrospective study included patients with CS who required mechanical circulatory support (MCS) at Health Sciences North, Sudbury, Ontario. The analysis aimed to accomplish 2 objectives: first, to review the outcomes associated with use of Impella (Abiomed, Danvers, MA) and, second, to assess the feasibility of establishing a shock team to facilitate the local implementation of VA-ECMO. The primary endpoint was in-hospital mortality. Results: The outcomes of 15 patients with CS who received Impella between 2015 and 2021 were reviewed. Their average age was 65 years (standard deviation [SD]: 13), and 8 patients (53%) were female. CS was ischemic in 12 patients (80%). Transfemoral Impella CP (cardiac power) was the most frequently used (93%). Thirteen patients (87%) died during the index hospital stay post-Impella because of progressive circulatory failure. The shock team was established following consultations with several Canadian MCS centres, leading to the development of a protocol to guide use of MCS. There have been 4 cases in which percutaneous VA-ECMO using Cardiohelp (Getinge/Maquet, Wayne, NJ) has been used; 3 (75%) survived beyond the index hospitalization. Conclusions: This analysis demonstrated the feasibility of implementing a shock team in remote Northern Ontario, enabling the use of VA-ECMO with success in a centre with a sizeable rural catchment area. This initiative helps address the gap in cardiac care outcomes between rural and urban areas in Ontario.

Introduction: En dépit des avancées des soins aux patients en phase critique et de la revascularisation coronarienne, les résultats du choc cardiogénique (CC) semblent mauvais. La mise en place d'une équipe de choc et l'utilisation de l'oxygénation extracorporelle (ECMO, de l'anglais extracorporeal membrane oxygenation) par voie veino-artérielle (VA) (VA-ECMO) ont été associées à de meilleurs résultats du CC, mais on ignore sa faisabilité dans les régions éloignées et rurales. Méthodes: La présente étude rétrospective portait sur des patients en CC qui ont eu besoin d'une assistance circulatoire mécanique (ACM) à Horizon Santé-Nord, à Sudbury, en Ontario. L'analyse visait 2 objectifs : le premier objectif était de passer en revue les résultats associés à l'utilisation de Impella (Abiomed, Danvers, MA) et, le deuxième était d'évaluer la faisabilité de la mise en place d'une équipe de choc pour faciliter la mise en œuvre locale de la VA-ECMO. Le principal critère d'évaluation était la mortalité intrahospitalière. Résultats: Nous avons passé en revue les résultats cliniques de 15 patients ayant subi un CC qui avaient reçu une Impella entre 2015 et 2021. L'âge moyen était de 65 ans (écart type [ET] : 13), et 8 patients (53 %) étaient des femmes. Le CC était d'origine ischémique chez 12 patients (80 %). L'Impella CP (cardiac power, soit la pompe cardiaque) par voie transfémorale était la plus fréquemment utilisée (93 %). Treize patients (87 %) sont morts durant le séjour de référence à l'hôpital après l'utilisation de l'Impella en raison d'insuffisance circulatoire progressive. La mise en place de l'équipe de choc à la suite des consultations dans plusieurs centres canadiens d'ACM a mené à l'élaboration d'un protocole d'utilisation de l'ACM. Il y a eu 4 cas chez lesquels la VA-ECMO par voie percutanée à l'aide de Cardiohelp (Getinge/Maquet, Wayne, New Jersey, É.-U.) a été utilisée ; 3 (75 %) ont survécu après l'hospitalisation de référence. Conclusions: Cette analyse a démontré la faisabilité de la mise en place d'une équipe de choc dans les régions éloignées du nord de l'Ontario, qui a permis d'utiliser efficacement la VA-ECMO dans un centre d'une circonscription hospitalière rurale non négligeable. Cette initiative aide à remédier à l'écart des résultats en soins cardiaques entre les régions rurales et urbaines de l'Ontario.

Medicine education in a pediatric oncology setting: What can we do better?

Background: When patients feel more involved in their care, there tends to be a higher rate of adherence and improved health outcomes. This can be more difficult to achieve in pediatric care since children have varying levels of medicine comprehension and parents are an integral component of the child's learning. Objectives: This study aimed to determine the satisfaction of children and families being treated for cancer with their medicine education and determine areas for improvement. Methods: Semi-structured interviews were conducted over six months (2016/2017) with families and children with cancer, ages 7 to 19 years, (n = 6) and healthcare providers (n = 9) to assess the current method of medicine education delivery. Results: Families reported increased stress and anxiety levels at the time of diagnosis, negatively impacting their information retention. Patients, families, and healthcare providers reported inconsistent education delivery, including varying amounts of information throughout the treatment and inconsistencies between providers, such as medication names. Parents mentioned a desire for a more consistent and standardized delivery of medicine education, which was found to be helped by a pharmacist-led approach. Receiving supplemental written materials to support verbal education helped with learners' understanding and information retention. Ensuring that the parents are comfortable and familiar with the medicines is a significant component of medicine teaching in pediatric care because they are often responsible for the child's medications and their children see them as a trusted source of information. Ensuring parents' needs are met translates to improved medicine adherence for children with cancer. Conclusion: Medicine education should occur sometime post-diagnosis once the patient/family has had time to adjust and the anxiety lessens. Medicine education should be given as consistently as possible by a recurring member of the care team, ideally the pharmacist. The learners' ability to understand and retain information should be individually assessed to determine the delivery of medicine education. Motivating and empowering learners, including children, through frequent medicine encounters could help improve adherence, patient health outcomes, and quality of life and make them more self-managing throughout life.

Intermediate-term Outcomes Following a Case Series of Reoperations for Medtronic Freestyle Stentless Aortic Valves.

Background: Data are limited on long-term outcomes in patients who have undergone a reoperation following failure of a stentless aortic valve. Methods: Between 2006 and 2016, a retrospective analysis was performed on 24 patients who underwent open aortic valve replacement surgery for a failed stentless aortic valve prosthesis at Health Sciences North, Sudbury, Ontario, Canada. The primary outcome was a low mortality rate from cardiac-related deaths after 5 years. Results: All patients underwent insertion of a Medtronic Freestyle bioprosthesis (Minneapolis, MN) implanted using the modified subcoronary technique for their initial operation. The interval from the first operation to the stentless redo surgery ranged from 6 to 13 years. Aortic valve reoperation was performed for structural valve deterioration in 96% (n = 23) of the cases. Reoperations involved a removal of the stented valve leaflets and standard aortic valve replacement within the stentless casing in 20% (n = 5) of the cases, with the remaining cases requiring complete removal of the stentless prosthesis and aortic valve replacement. In those in whom a complete removal of the stentless valve was possible (n = 19), no disruption of the native aortic root occurred, with a 0% rate of conversion to a Bentall procedure. No intraoperative mortality occurred. The 30-day and 10-year operative mortality rates were 4% and 16%, respectively. Conclusions: Redo surgery for failing stentless valves can be done with relatively low risk and with acceptable long-term outcomes without resorting to root-replacement techniques.

Contexte: Il existe peu de données sur les résultats à long terme chez les patients qui ont subi une réintervention chirurgicale après une défaillance d'une valve aortique sans armature (stentless) ayant été implantée. Méthodologie: Nous avons réalisé une analyse rétrospective, de 2006 à 2016, auprès de 24 patients ayant subi une intervention chirurgicale invasive de remplacement de valve aortique en raison de la défaillance d'une prothèse aortique sans armature à l'hôpital Health Sciences North situé à Sudbury (Ontario), au Canada. Le paramètre principal d'évaluation était un faible taux de mortalité d'origine cardiaque après 5 ans. Résultats: Tous les patients avaient initialement subi l'implantation d'une bioprothèse Medtronic Freestyle (Minneapolis, Minnesota) par la technique sous-coronaire modifiée. La période écoulée entre la première intervention chirurgicale et la réintervention au niveau de la valve sans armature allait de 6 à 13 ans. Dans 96 % des cas (n = 23), la réintervention était réalisée en raison d'une détérioration de structure de la valve aortique. La réintervention avait consisté en un retrait des cuspides avec armature et un remplacement de valve aortique standard dans la membrane sans armature dans 20 % des cas (n = 5) et un retrait complet de la prothèse sans armature avec remplacement de la valve aortique avait été nécessaire dans les autres cas. Chez les patients pour qui le retrait complet de la valve sans armature a été possible (n = 19), aucune déchirure de la racine aortique native n'est survenue et le taux de passage à une intervention de Bentall était de 0 %. Aucun décès peropératoire n'est survenu. Les taux de mortalité à 30 jours et à 10 ans s'élevaient à 4 % et à 16 %, respectivement. Conclusions: La réintervention chirurgicale après la défaillance d'une valve aortique sans armature peut être réalisée avec des risques re-lativement faibles et des résultats à long terme acceptables sans avoir recours à des techniques de remplacement de la racine aortique.

The Safety of Early Discharge Following Transcatheter Aortic Valve Implantation Among Patients in Northern Ontario and Rural Areas Utilizing the Vancouver 3M TAVI Study Clinical Pathway.

Background: Early hospital ( < 48 hours) discharge following transcatheter aortic valve implantation (TAVI) is an increasingly adopted practice; however, data on the safety of such an approach among patients residing in North Ontario, including remote and medically underserved areas, are lacking. Methods: This retrospective study included patients who underwent TAVI in Sudbury, Ontario. The safety of early discharge after implementation of the Vancouver 3M (multidisciplinary, multimodality, but minimalist) clinical pathway was assessed. The primary endpoint was 30-day mortality. Resource utilization before vs after 3M clinical pathway implementation was also compared. Results: A total of 291 patients who underwent TAVI between 2012 and 2021 were included in the study. One in-hospital death (0.6%) occurred after the 3M clinical pathway implementation, with no mortality observed beyond hospital discharge. Eleven patients (6.7%) required rehospitalization within 30 days. The need for mechanical ventilation and surgical vascular cut-down declined from 100% and 97%, respectively, at baseline, to 6% and 2%. The number of patients receiving TAVI on a given procedural day increased from 2 to 3 patients. The median post-TAVI hospital length of stay decreased from 5 days (2-6 days) to 1 day (1-3 days) after 3M clinical pathway implementation. Conclusions: Following TAVI, early discharge of selected patients residing in Northern Ontario, including rural areas, using the Vancouver 3M clinical pathway was associated with favourable outcomes, short length of stay, and more-efficient resource utilization. These data can help improve healthcare efficiency and bridge variations in TAVI funding and accessibility in underserved locations.

Contexte: Il est de plus en plus admis d'accorder un congé rapide de l'hôpital (< 48 heures) après une implantation valvulaire aortique par cathéter (IVAC); toutefois, on ne dispose pas de données sur l'innocuité de cette pratique pour les patients du nord de l'Ontario, y compris ceux qui résident en régions éloignées moins bien desservies par les services médicaux. Méthodologie: Cette étude rétrospective a porté sur des patients ayant subi une IVAC à Sudbury (Ontario). L'innocuité d'un congé rapide après l'implantation selon le parcours de soins Vancouver 3M (multidisciplinaire, multimodal, mais minimaliste) a été évaluée. Le principal paramètre d'évaluation était la mortalité à 30 jours. Une comparaison de l'utilisation des ressources avant et après la mise en œuvre du parcours de soins 3M a également été effectuée. Résultats: Au total, 291 patients ayant subi une IVAC entre 2012 et 2021 ont été inclus dans l'étude. Un décès à l'hôpital (0,6 %) est survenu après la mise en œuvre du parcours de soins 3M, et aucune mortalité n'a été relevée après le congé de l'hôpital. Onze patients (6,7 %) ont dû être réhospitalisés dans les 30 jours suivants. Le recours à la ventilation mécanique et à la dénudation vasculaire a chuté, passant de 100 % et 97 % au départ, respectivement, à 6 % et 2 %. Le nombre de patients par jour d'intervention subissant une IVAC est passé de deux à trois patients. À la suite de la mise en œuvre du parcours de soins 3M, la durée médiane du séjour à l'hôpital après une IVAC est passée de cinq jours (deux à six jours) à un jour (un à trois jours). Conclusions: Après une IVAC, le congé rapide de patients sélectionnés habitant dans le nord de l'Ontario, y compris ceux habitant en région rurale, selon le parcours de soins Vancouver 3M a été associé à des résultats de santé favorables, à une durée courte d'hospitalisation et à une utilisation plus efficace des ressources. Ces données peuvent contribuer à améliorer l'efficacité des soins de santé et à combler des écarts liés aux variations du financement et de l'accessibilité des IVAC dans les régions moins bien desservies.

The Role of Neuroimaging in the Determination of Brain Death.

BACKGROUND AND PURPOSE: Brain death determination (BDD) is primarily a clinical diagnosis, where death is defined as the permanent loss of brainstem function. In scenarios where clinical examinations are inaccurate, ancillary imaging tests are required. The choice of ancillary imaging test is variable, but the common denominator for all of them is to establish a lack of cerebral blood flow. The purpose of this study was to compare the diagnostic accuracy and interrater reliability of different ancillary imaging tests used for BDD. METHODS: Archival data were retrospectively analyzed for all patients who underwent any ancillary imaging test for BDD at our institution. The results of ancillary imaging tests were compared with, the reference standard, the clinical checklist for declaration of brain death. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of different ancillary imaging tests for BDD were performed. Interobserver agreement between two observers was measured using kappa statistics for each of the imaging modalities. RESULTS: A total of 74 patients underwent 41 computer tomography perfusion (CTP), 54 CT angiogram, 15 radionuclide scans, 1 cerebral angiogram, 3 magnetic resonance imaging, and 71 nonenhanced CT (NECT) head for BDD. All ancillary tests (except NECT head) showed 100% specificity and PPV. CTP had the highest sensitivity and NPV. All ancillary imaging tests demonstrated very high interrater reliability. CONCLUSIONS: The uses of ancillary imaging tests for BDD are increasing. Within this study's limitations, CTP followed by radionuclide scan were found to be the most accurate and reliable ancillary imaging test for BDD.

The ABCs of RVO: a review of retinal venous occlusion.

Retinal vein occlusions are important causes of loss of vision; indeed, they are the second most common retinal vascular disease, following diabetic retinopathy. For this reason alone, primary eye-care providers must be well versed in diagnosis and management. Risk factors, though not universally agreed upon, include but are not limited to advancing age, systemic hypertension, arteriolarsclerosis, diabetes, hyperlipidaemia, blood hyperviscosity, thrombophilia, ocular hypertension and glaucoma. Typically, visual loss is secondary to macular oedema and/or retinal ischaemia. Treatment modalities have included observation, systemic thrombolysis and haemodilution, radial optic neurotomy, chorioretinal anastomosis, vitrectomy, laser photocoagulation and intravitreal injection of anti-inflammatory and, most recently, anti-vascular endothelial growth factors.

What do children with cancer know about their medications? / ¿Qué saben los niños con cáncer sobre sus medicaciones?

Objectives: To explore the health literacy of children diagnosed with Acute Lymphoblastic Leukemia (ALL) through their knowledge of their medications. Methods: Within the Basic Interpretive approach to qualitative research, semi-structured interviews were conducted with children from ages 6 to18 years (n=16) between May and September 2009 to determine their knowledge of medication properties, medication habits and medication teaching. REB approval was obtained. Results: The younger children (mean age 7.5 years) correctly answered, on average, 51% of the questions on colour, 26% of the questions on name, 25% of the questions on frequency, and 8% of the questions on the purposes of their medications. The older children (mean age 16 years) scored at least 35% higher for each characteristic. All of the younger children reported that physicians consistently directed medication education to parents only, and that the younger children were rarely present during these sessions. 13 of the 16 children stated that they want to learn more about and be more involved in education sessions addressing their medications. Conclusion: Children with ALL at the IWK Health Centre do not have a good knowledge of their medications, however most children expressed that they want to know more about their medications (AU)

Objetivos: Explorar la alfabetización en salud de los niños diagnosticados de leucemia linfoblástica aguda (LLA) a través de su conocimiento sobre la medicación. Métodos: Con un abordaje de Interpretación Básico de investigación cualitativa, se realizaron entrevistas semi-estructuradas a niños de 6 a 18 años (n=16) entre mayo y septiembre de 2009 para determinar su conocimiento de las propiedades de la medicación, costumbres de medicación y enseñanzas de la medicación. Se obtuvo aprobación de la Comisión de Ética. Resultados: Los niños más jóvenes (edad media 7,5 años) respondían correctamente a una media de 51% de las preguntas sobre color, 26% de las preguntas sobre el nombre, 25% de las preguntas sobre frecuencia, y 8% de las preguntas sobre objetivos de la medicación. Los niños mayores (edad media 16 años) puntuaron al menos en el 35% para cada característica. Todos los niños más jóvenes informaron que normalmente el medico realizada la educación sobre la medicación a sus padres solamente, y que los más jóvenes raramente estaban en esas sesiones. 13 de los 16 niños afirmaron que querían aprender más sobre la medicación y estar más involucrados en las sesiones educativas realizadas sobre su medicación. Conclusión: Los niños con LLA en el IWK Health Centre no tienen un buen conocimiento de sus medicaciones, sin embargo, la mayoría de los niños expresó que deseaban saber más sobre sus medicaciones (AU)

What do children with cancer know about their medications?

OBJECTIVE: To explore the health literacy of children diagnosed with Acute Lymphoblastic Leukemia (ALL) through their knowledge of their medications. METHODS: Within the Basic Interpretive approach to qualitative research, semi-structured interviews were conducted with children from ages 6 to18 years (n=16) between May and September 2009 to determine their knowledge of medication properties, medication habits and medication teaching. REB approval was obtained. RESULTS: The younger children (mean age 7.5 years) correctly answered, on average, 51% of the questions on colour, 26% of the questions on name, 25% of the questions on frequency, and 8% of the questions on the purposes of their medications. The older children (mean age 16 years) scored at least 35% higher for each characteristic. All of the younger children reported that physicians consistently directed medication education to parents only, and that the younger children were rarely present during these sessions. 13 of the 16 children stated that they want to learn more about and be more involved in education sessions addressing their medications. CONCLUSIONS: Children with ALL at the IWK Health Centre do not have a good knowledge of their medications, however most children expressed that they want to know more about their medications.

Persistence of marrow stromal cells implanted into acutely infarcted myocardium: observations in a xenotransplant model.

OBJECTIVE: It has been reported that unmatched adult bone marrow stromal cells could be tolerated by immune-competent allotransplant or xenotransplant recipients under various conditions. This study examined whether xenogeneic bone marrow stromal cells implanted immediately after myocardial infarction can survive and differentiate, attenuating deterioration in left ventricular function. METHODS: In groups I and II (n = 34), myocardial infarctions were created in immunocompetent adult Lewis rats by proximal left coronary artery ligation. In group I, 3 x 10(6)lacZ-labeled mouse bone marrow stromal cells were immediately injected into the peri-infarct area of the left ventricle, whereas in group II, only culture medium was injected. There were 10 early and 4 late deaths. At 4 weeks after injection, hearts were stained for beta-galactosidase and troponin IC. In groups IIIA and IIIB, lacZ-labeled mouse skin fibroblasts were implanted into rat myocardium (n = 10 each) with and without left coronary artery ligation, respectively, and the rats were killed serially. In group IV, animals underwent sham surgery (n = 5, no deaths). At 4 weeks, surviving rats in groups I, II, and IV (n = 10, n = 10, and n = 5, respectively) underwent blinded transthoracic echocardiography for ventricular function studies. RESULTS: In group I, labeled mouse-derived bone marrow stromal cells were found within rat myocardium that stained positively for troponin IC 4 weeks after implantation. Functionally, mean left ventricular ejection fraction (P = .007), stroke volume (P = .03), and fractional shortening (P = .02) were all significantly higher in group I than in group II. In groups IIIA and IIIB, mouse fibroblasts induced cellular infiltration with rapid loss of donor cells. No labeled cells were found after 4 days. In group IV, there was no change in cardiac function. CONCLUSION: Xenogeneic bone marrow stromal cells implanted into acutely ischemic myocardium induced by coronary artery ligation were immunologically tolerated, survived and differentiated, resulting in a cardiac chimera which improved left ventricular function. This unique immunologic tolerance may suggest the feasibility of using bone marrow stromal cells as universal donor cells.

Low postoperative hematocrit increases cerebrovascular damage after hypothermic circulatory arrest.

OBJECTIVE: The objective of this study was to evaluate the systemic and cerebral effects of different postoperative hematocrit management following cardiopulmonary bypass and deep hypothermic circulatory arrest. DESIGN: Animal case study. SETTING: Laboratory. SUBJECTS: Four-week-old Yorkshire piglets. INTERVENTIONS: Twelve piglets were subjected to cardiopulmonary bypass (hematocrit = 25%) and 100 mins of deep hypothermic circulatory arrest (15 degrees C). After weaning cardiopulmonary bypass, they were randomized to either group L or H, in which the postoperative hematocrit was maintained approximately 20% vs. approximately 30%, respectively, and survived for 6 hrs. MEASUREMENTS AND MAIN RESULTS: Changes in body weight, bioimpedance, and colloid oncotic pressure were assessed. Near-infrared spectroscopy and immunohistochemical assays for cerebral transforming growth factor-beta(1) and caspase-3 were performed. Postoperative weight gain (kg) and decreases in bioimpedance (ohms) were significantly less in group H (1.5 +/- 0.2 [H] vs. 2.4 +/- 0.6 [L], p = .01; 39.3 +/- 15.5 [H] vs. 89.1 +/- 29.6 [L], p = .01). Mean colloid oncotic pressure (mm Hg) was significantly higher in group H (10.8 +/- 1.6 [H] vs. 8.2 +/- 0.8 [L], p = .01) at 6 hrs postoperatively. Oxyhemoglobin, oxidized cytochrome aa(3) (muM x differential path-length factor), and tissue oxygenation index (%) were significantly better in group H (65.7 +/- 31.8 [H] vs. -104.7 +/- 55.2 [L], p = .0001; 0.52 +/- 4.1 [H] vs. -12.8 +/- 6.1 [L], p = .0001, and 55.7 +/- 4.6% [H] vs. 45.3 +/- 6.4% [L], p = .004, respectively). Cerebral transforming growth factor-beta(1) and caspase-3 scores were significantly better in group H (3.0 +/- 0.6 [H] vs. 1.9 +/- 0.9 [L], p = .04 and 1.8 +/- 0.5 [H] vs. 3.2 +/- 0.8 [L], p = .02, respectively). Mean arterial pressure (mm Hg) was consistently higher with group H (94.7 +/- 13.0 [H] vs. 78.3 +/- 11.5 [L], p = .003) despite comparable central venous pressure ( approximately 11 mm Hg). CONCLUSIONS: Lower postoperative hematocrit was associated with increased fluid retention, lower perfusion pressure, and worse cerebrovascular injury following deep hypothermic circulatory arrest. Postoperative hematocrit management may have profound systemic and cerebral effects after deep hypothermic circulatory arrest and merits further investigation.