Battlefield acupuncture to treat low back pain in the emergency department.

INTRODUCTION: Battlefield acupuncture (BFA) is an ear acupuncture protocol used by the military for immediate pain relief. This is a pilot feasibility study of BFA as a treatment for acute low back pain (LBP) in the emergency department (ED). METHODS: Thirty acute LBP patients that presented to ED were randomized to standard care plus BFA or standard care alone. In the BFA group, outcomes were assessed at the time of randomization, 5 min after intervention, and again within 1 h after intervention. In the standard care group outcomes were assessed at the time of randomization and again an hour later. Primary outcomes included post-intervention LBP on a 10-point numeric pain rating scale (NRS) and the timed get-up-and-go test (GUGT). t-Test and chi squared tests were used to compare differences between groups demographics to evaluate randomization, and Analysis of Covariance (ANCOVA) was used to assess differences in primary/secondary outcomes. RESULTS: We randomized 15 patients to BFA plus standard care, and 15 patients to standard care alone. Demographics were similar between groups. Post-intervention LBP NRS was significantly lower in the BFA group compared with the standard care group (5.2 vs. 6.9, ANCOVA p = 0.04). GUGT was similar between groups (21.3 s vs. 19.0 s, ANCOVA p = 0.327). No adverse events from acupuncture were reported. DISCUSSION: This pilot study demonstrates that BFA is feasible as a therapy for LBP in the ED. Furthermore, our data suggest that BFA may be efficacious to improve LBP symptoms, and thus further efficacy studies are warranted. (Clinicaltrials.gov registration number NCT02399969).

Auricular Acupuncture in Emergency Department Treatment of Acute Pain.

The National Institutes of Health and the World Health Organization note that acupuncture is a safe and effective treatment for pain. Nonopioid treatment options for moderate to severe acute pain in the emergency department (ED) are limited. Additional strategies for managing acute pain in the ED are needed. Auricular Battlefield Acupuncture has been described as a simple, safe, rapid, and effective analgesic option to opioid medications in managing acute pain. We describe 4 cases in which emergency physicians with brief training performed this auricular acupuncture protocol to treat patients with acute pain in EDs when opioid analgesia was not an acceptable option.

Congenital absence of inferior vena cava with azygos continuation revealed by vascular echo in a patient with pulmonary thromboembolism and deep vein thrombosis: a case report.

A 44-year-old man with an isolated anomaly of azygos continuation of the inferior vena cava (IVC) presented with dyspnea due to pulmonary thromboembolism (PTE) and deep-vein thrombosis (DVT). Sono-graphic examination disclosed not only pulmonary hypertension and DVT, but also infrahepatic interruption of the IVC with azygos continuation. A rare anomaly of azygos continuation of IVC could cause DVT and PTE. Vascular echo could play an important role in the examination of DVT and/or venous anomalies.

Reoperation for mid-term failure of a freestyle bioprosthesis using a full root technique --a surgical case--.

The aortic root of a 30-year-old man was replaced with a Freestyle stentless aortic bioprosthesis for aortic regurgitation associated with annuloaortic ectasia. His clinical course was uneventful, and he was discharged without complications. Three years and six months after surgery, he presented with a high fever. Four years after surgery, transthoracic echocardiography revealed severe aortic regurgitation. We performed exploratory surgery and discovered a torn left coronary cusp of the Freestyle bioprosthesis. Organized vegetation was adherent to the left coronary cusp leaflet. The non-coronary cusp and the right coronary cusp were normal. The diagnosis was aortic regurgitation due to valve failure related to infective endocarditis. Consequently, we reconstructed the aortic root with a composite graft (26-mm Valsalva graft and a 21-mm ON-X mechanical valve).

Mitral valve repair for 52 patients with severe left ventricular dysfunction.

BACKGROUND: Mitral valve (MV) repair is considered to provide more favorable results than MV replacement. MV repair in a patient with severe left ventricular (LV) dysfunction could be associated with higher early and late mortality. Surgical indication of MV repair for those with low LV ejection fraction (LVEF) is still controversial. PATIENTS AND METHODS: Fifty-two patients with severe mitral regurgitation (MR) and severe LV dysfunction (EF < 35%) underwent MV repair with or without concomitant procedure. The commonest etiology of MV disease was ischemic origin (78.8%), which underwent annuloplasty alone. Their pre- and perioperative parameters were analyzed to identify the risk factor for mortality. The follow-up data of hospital survivors were collected. RESULTS: Early mortality was 9.6%. The cause of all deaths was low cardiac output syndrome. Actuarial survival was 81.6% at 2 years and 76.5% at 5 years. Multivariate analyses revealed chronic hemodialysis and EF < 25% to be the risk factors for early and late mortality. Among hospital survivors, significant improvement of LVEF (29.9 to 37.4%) and reduction of LV diastolic dimension (62.8 to 57.9 mm) were observed during follow-up. CONCLUSION: MV repair is effective to improve long-term prognosis of high-risk patients of severe MR with severe LV dysfunction.

Early results of Bentall-type operations during the last 10 years: comparison of mechanical valves and stentless bioprostheses.

UNLABELLED: OBJECTIVE. Various types of prostheses have been used for combined diseases of the aortic root and ascending aorta. METHODS: All Bentall-type operations (n=64) between 1996 and 2005 were retrospectively studied, comparing different types of prosthesis in the aortic position. The patients were 29-87 years old (mean 59.5 +/- 14.0 years) and included 47 men and 17 women. Mechanical valves, stentless bioprostheses (Freestyle), stented bioprostheses, and a homograft were used in 31, 29, 3, and I patients, respectively. Early results, especially hemodynamics, were analyzed among two groups: mechanical valve group (M-group) and Freestyle group (F-group). RESULTS: The average age was significantly higher in the F-group (62.8 +/- 12.7 years) than in the M-group (54.9 +/- 14.0 years) (P = 0.025). The implanted valve was significantly larger in the F-group (26.0 +/- 2.3 mm) than in the M-group (23.5 +/- 2.1mm) (P = 0.000). The estimated effective orifice area of the prosthesis was significantly larger in the F-group (2.23 +/- 0.38 cm2) than in the M-group (1.84 +/- 0.49 cm2) (P = 0.001). The pressure gradient across the prosthesis was significantly lower in the F-group (18.6 +/- 5.5 mmHg) than in the M-group (25.4 +/- 7.6 mmHg) (P = 0.001). CONCLUSION: The Bentall-type procedure using the Freestyle valve has an advantage regarding hemodynamics compared to the procedure employing mechanical prostheses.

Giant right atrial myxoma associated with tricuspid regurgitation.

A 55-year-old woman presented with dyspnea on effort for half a year that had progressed with time. Echocardiography showed a giant spherical mass (6 cm diameter) in the right atrium occupying almost the entire space of the atrium. The mass was attached to the interatrial septum with a wide base. There was moderate to severe tricuspid regurgitation. Emergency operation was performed via median sternotomy. Under cardiopulmonary bypass, the tumor was excised with the interatrial septum where the tumor was arising. The defect was closed using an autologous pericardial patch. Tricuspid annuloplasty was carried out with no residual tricuspid regurgitation.

[Coronary artery bypass grafting and replacement of aortic root and ascending aorta; report of a case].

An 87-year-old man was referred to our hospital for chest oppression and syncope attack due to aortic stenosis. Further examination revealed severe aortic stenosis (pressure gradient of 107 mmHg, aortic valve area of 0.75 cm2), ascending aortic aneurysm (60 mm in diameter) and triple-vessel disease of coronary arteries. Therefore, a surgical operation was indicated electively. Under cardiopulmonary bypass with normothermia, coronary artery bypass grafting (CABG) was performed. Then the aortic root and the ascending aorta were replaced with a Freestyle valve (27 mm) and a woven Dacron graft (30 mm Hemashield with 1 branch), respectively. Duration of cardiopulmonary bypass and aortic cross-clamp was 267 and 203 minutes, respectively. Postoperative course was uneventful. On the 14th postoperative day, he underwent coronary and graft angiography, which showed all the grafts were patent with good flow. He was successfully discharged on the 19th postoperative day.

The prostacyclin analogue beraprost sodium prevents occlusion of bypass grafts in patients with lower extremity arterial occlusive disease: a 20-year retrospective study.

Although conventional bypass grafting is commonly used to treat ischemia in lower extremities, graft failure often occurs. This study retrospectively analyzed the factors that affect graft patency to help establish more effective treatment of obstructive arterial disease of the lower limbs. Kaplan-Meier analysis was used to estimate graft patency in 90 legs of 80 patients who underwent femoropopliteal bypass (28 vein grafts and 62 expanded polytetrafluoroethylene grafts) between 1984 and 2003. Patients were randomly selected for graft materials in sequential surgical treatment order. After initial analysis, several risk factors and postoperative medication regimens were analyzed to ascertain any association with graft failure. The overall mean patency period for femoropopliteal bypass was 10.5 +/- 0.7 years. Graft occlusion occurred in 20 limbs. Neither the materials composing the grafts nor the position of distal anastmosis had any influence on patency maintenance. Graft occlusion rates were significantly greater in patients with either diabetes (p = 0.0049) or rest pain before surgery (p = 0.0011). Postoperative administration of beraprost sodium significantly increased the patency period (p = 0.0082). Diabetes and rest pain before surgery are important factors for late graft failure after femoropopliteal bypass. Our data also suggest that administration of beraprost sodium increases the graft patency period.

End-tidal carbon dioxide monitoring indicates recovery from cardiogenic shock in patients receiving percutaneous cardiopulmonary support.

The aim of this study was to examine the prognostic value of monitoring end-tidal carbon dioxide (ETCO(2)) levels for patients in cardiogenic shock undergoing percutaneous cardiopulmonary support (PCPS). Fifteen patients in whom PCPS was used to treat cardiogenic shock were enrolled in this study. For hemodynamic measurements, a thermodilution catheter was inserted into the pulmonary artery and an infrared absorption sensor was placed in the main stream of exhaled air between the respiration tube and the respirator to measure ETCO(2) levels. Nine patients (group II, 60%) died of multiple organ failure. In the six survivors (group I), there was a significant increase in average ETCO(2) level from 8.8 +/- 3.9 mmHg before treatment to 20.5 +/- 2.1 mmHg 24 h after the start of PCPS compared with values in group II patients (8.8 +/- 3.9 mmHg, P = 0.0411). Also, serum lactate concentrations fell significantly in group I patients (group I 2.8 +/- 0.47 mmol/l, group II 9.0 +/- 2.31 mmol/l, P = 0.0435). The mean ETCO(2) level in group I patients gradually returned to 23 mmHg, which was within the normal healthy range; these patients were successfully weaned from PCPS. These results suggest that, in cardiogenic shock patients, ETCO(2) level is a possible index of cardiac recovery during PCPS support.

Is measurement of plasma brain natriuretic peptide levels a useful test to detect for surgical timing of valve disease?

BACKGROUND: The optimal timing of valve surgery is very important. In patients who are severely symptomatic, the marked improvement in symptomatic status observed following successful valve surgery. However, in patients with no or only mild symptoms, the decision is more difficult. The aim of this retrospective study was to determine whether the measurement of plasma brain natriuretic peptides (BNP) levels is useful to decide surgical timing for valve disease. METHODS: Fifty-one patients with valve disease underwent single valve surgery (mitral stenosis, MS, 13; mitral regurgitation, MR, 16; aortic stenosis, AS, 14; aortic regurgitation, AR, 8 patients). Blood samples, echocardiographic and cardiac catheterization data were obtained before operation and echocardiographic examination were performed after 1-year of operations. RESULTS: In patients subjected to single heart valve surgery, plasma BNP mean levels were 214.6+/-48.5 pg/ml. In plasma BNP levels, there was only significant difference between MS and AS group (MS 67.5+/-9.7 vs. AS 314.3+/-112.0 pg/ml, P=0.04). There were no relationships between plasma BNP levels and pre-operative cardiac functions. After 1-year of the valve surgery, NYHA functional class was reduced in 36 patients (70.6%) and plasma BNP levels before the surgery significantly correlated with post-operative NYHA functional class. CONCLUSIONS: In this retrospective study, patients with high plasma BNP levels significantly impaired the improvement of clinical symptoms after surgery. We have suggested that plasma BNP levels is useful for detecting asymptomatic valvular disease, and is a clinical marker useful in determining the optimal surgical timing.

Decreased plasma brain natriuretic peptide levels after a successful maze procedure.

BACKGROUND AND AIM OF THE STUDY: Previous reports indicate that plasma levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) increase in atrial fibrillation (AF), but decrease after successful direct current (DC) cardioversion. Although the maze procedure is the only curative therapy for AF, the effects on atrial and left ventricular function remain unclear. The study aim was to determine whether plasma ANP and BNP levels decrease after the maze procedure in patients with mitral valve disease. METHODS: Twenty-seven patients either with (n = 23) or without (n = 4) AF underwent mitral valve surgery; of these patients, 13 underwent a maze procedure for chronic AF. Blood samples and echocardiographic data were obtained before and at one year after surgery. RESULTS: Ten patients with AF achieved sinus rhythm (SR) or junctional rhythm after the maze procedure. In patients subjected to mitral valve surgery, mean plasma levels of ANP and BNP were 59.8 +/- 11.9 and 139.2 +/- 53.7 pg/ml, respectively. ANP and BNP plasma levels fell significantly after surgery (to 32.1 +/- 4.1 and 46.7 +/- 10.2 pg/ml, respectively; p = 0.04 and p = 0.004). In patients with successful maze procedure, plasma levels of BNP and left ventricular end-diastolic dimension (LVDd) were significantly decreased by 35.7% and 82.7% compared with preoperative values (BNP, 35.7 +/- 4.9% for SR versus 83.4 +/- 9.6% for AF, p = 0.008; LVDd, 82.7 +/- 3.7% for SR versus 97.0 +/- 3.2% for AF, p = 0.0159). CONCLUSION: A successful maze procedure significantly decreased LVDd and plasma levels of BNP after surgery. These results show that the maze procedure is effective in improving left ventricular diastolic dysfunction for a mid-term period in patients with mitral valve disease.

Biventricular pacing in a patient with severe congestive heart failure.

We report a case of dilated cardiomyopathy with severe congestive heart failure (ejection fraction: 19%) and complete left bundle branch block (QRS duration: 240 ms) 13 years after aortic valve replacement. Permanent biventricular pacing was implanted by inserting a left ventricular lead thorough a small left thoracotomy following intravenous insertion of right atrial and ventricular endocardial leads. Biventricular pacing increased hemodynamic parameters such as blood pressure, cardiac output and decreased mitral regurgitation. Symptoms and exercise tolerance improved dramatically. Left ventricular epicardial lead insertion via a small thoracotomy is thus useful in selected patients.

Severe hemolysis due to cloth wear 23 years after aortic valve replacement on a Starr-Edwards ball valve model 2320.

Despite iron substitution therapy, a patient developed severe hemolytic anemia 23 yr after insertion of a cloth-covered Starr-Edwards model 2320 aortic valve prosthesis. The prosthesis showed no sign of significant dysfunction. Upon removal, it showed extensive cloth wear on the inner surface of all three struts; one strut was completely denuded of its cloth covering. Hemolysis immediately resolved after replacement with a St Jude aortic prosthesis.