Screening Electrocardiograms Have Low Utility in Medical Clearance Before Pediatric Inpatient Psychiatric Admission.

OBJECTIVES: Children presenting to the emergency department (ED) requiring psychiatric admission often undergo screening electrocardiograms (ECG) as part of the medical clearance process. The diagnostic yield of screening ECGs for this purpose has not been reported. The purpose of this study was to determine the clinical utility of screening ECGs in children and adolescents requiring acute inpatient psychiatric admission. METHODS: A single-center retrospective study of patients aged 5 to 18 years who did not have documented indications for ECG and underwent screening ECG before psychiatric inpatient admission over a 2-year period was conducted. Abnormal ECGs were identified via chart review and were reinterpreted by a pediatric cardiologist to determine potential significance to psychiatric care. Impact on treatment and disposition was examined. RESULTS: From January 2018 through December 2019, 252 eligible pediatric patients had a screening ECG in the ED before psychiatric admission. Twenty-one (8.3%) of these ECGs were interpreted as abnormal, and 6 (2.4%) were determined to be potentially relevant to psychiatric care in the setting of specific medication use. The abnormal ECG interpretations resulted in additional workup and/or cardiology consultation for 7 (2.7%) patients but had no impact on psychiatric admission. CONCLUSIONS: In the absence of concerning individual or family history or cardiac symptoms, routine screening ECGs as part of medical clearance for psychiatric admission are not warranted given the low yield of meaningful findings. The decision to obtain an ECG should be made with careful consideration of medical history and in the presence of specific indications.

Just Culture: Practical Implementation for Radiologist Peer Review.

Peer review is a cornerstone of quality improvement programs and serves to support the peer learning process. Peer review in radiology incorporates the review of diagnostic imaging interpretation, interventional procedures, communication, and the evaluation of untoward patient events. A just culture is an environment in which errors and near-miss events are evaluated in a deliberately nonpunitive framework, avoiding a culture of blame and responsibility and focusing instead on error prevention and fostering a culture of continuous quality improvement. Adoption of a just culture requires careful attention to detail and relies on continuous coaching of individuals and teams to ensure future systems improvements and a culture of safety. The authors describe the practical implementation of a just culture framework for peer review in an academic radiology department and highlight its application to interpretive, noninterpretive, and procedural domains through case examples.

Invasive Hemodynamics of Pulmonary Disease and the Right Ventricle.

Pulmonary hypertension (PH) falls into 5 groups, as defined by the World Health Organization. Swan-Ganz catheters determine precapillary versus postcapillary PH. The hemodynamic values of PH at rest and with vasodilatory challenge categorize the etiology of PH and guide treatment. RV maladaptations to increased pulmonary vascular resistance (PVR) and the chronicity of the right ventricle's (RV) response to increased PH and/or increased PVR can be understood with pressure-volume (PV) loops constructed with use of conductance catheters. These PV loops demonstrate the RV's ability to increase stroke volume in acutely and chronically increased PVR.

Adsorbate-induced lifting of substrate relaxation is a general mechanism governing titania surface chemistry.

Under ambient conditions, almost all metals are coated by an oxide. These coatings, the result of a chemical reaction, are not passive. Many of them bind, activate and modify adsorbed molecules, processes that are exploited, for example, in heterogeneous catalysis and photochemistry. Here we report an effect of general importance that governs the bonding, structure formation and dissociation of molecules on oxidic substrates. For a specific example, methanol adsorbed on the rutile TiO2(110) single crystal surface, we demonstrate by using a combination of experimental and theoretical techniques that strongly bonding adsorbates can lift surface relaxations beyond their adsorption site, which leads to a significant substrate-mediated interaction between adsorbates. The result is a complex superstructure consisting of pairs of methanol molecules and unoccupied adsorption sites. Infrared spectroscopy reveals that the paired methanol molecules remain intact and do not deprotonate on the defect-free terraces of the rutile TiO2(110) surface.

Evaluation and Management of Concomitant Hypertrophic Obstructive Cardiomyopathy and Valvular Aortic Stenosis.

OPINION STATEMENT: The dilemma of the patient with both AS and LVOTO is now commonly encountered in clinical practice; indeed, physicians must be aware of the complex interaction and coexistent nature of both diseases, especially as both HOCM and TAVR have increased in awareness and prevalence. Importantly, the clinician must be aware of the complex interplay hemodynamically, with the two diseases confusing the TTE imaging and potentially affecting each other anatomically and clinically. There is no set guideline on how to approach this from a surgical or percutaneous approach, but we have outlined a set of recommendations which should serve the clinician and patient well. The three cases that are presented illustrate that methodical diagnosis in addition to the order of treatment do indeed matter. In the first case, there was AS and an underestimated LVOT gradient that was also present. Once the AS was corrected, the true LVOT gradient potential was evidenced and she decompensated, likely because there was a rapid decrease in afterload. Patients with concomitant LVOTO are not able to adjust quickly to the hemodynamic changes created by the rapid decline in afterload, as, for example, in HOCM patients who receive nitroglycerin. The second case demonstrated that when the LVOTO was severe and the AS nonsignificant (mild or moderate), the patient was able to live without symptoms for several years after successful alcohol septal ablation (ASA). She eventually needed an aortic valve and mitral valve replacement but that was postponed for several years until the AS became more significant, and the surgical risk was lowered by the elimination of the need for concomitant myectomy. In the last case, the patient was able to have both an ASA and TAVR within 3 months of each other without hemodynamic compromise. Indeed, this latter therapy sequence may be the best way to treat patients with both diseases in the future, as both ASA and TAVR continue to evolve into intermediate and lower-risk patient populations and the safety of ASA continues to be evident.

Utility of carotid duplex ultrasonography in a general inner-city hospital.

BACKGROUND: Carotid Duplex Ultrasonography (CDUS) is one of the non-invasive imaging modalities used to evaluate for carotid artery stenosis. However, it is often used in patients with coronary artery disease (CAD), peripheral artery disease (PAD), before heart surgery, syncope and non-specific neurological symptoms although its value is unclear. Our study aimed to further investigate the yield of CDUS in these conditions. METHODS: A retrospective analysis was conducted on 827 consecutive carotid ultrasounds ordered between March 2013 and August 2013 at Newark Beth Israel Medical Center. Clinical characteristics such as age, sex, smoking status, systemic hypertension, diabetes mellitus, CAD, PAD, carotid bruit and indications for carotid ultrasound were included. Significant cerebrovascular disease (sCBVD) was defined as greater than or equal to 50% diameter reduction in internal carotid arteries (ICA) or any degree of occlusion in vertebrobasilar system. RESULTS: Only 88 out of 827 (10.6%) patients had sCBVD. Using logistic regression analysis we identified age greater than 65 years (OR 2.1, 95% CI 1.2 to 3.7; P=0.006), carotid bruit (OR 7.8, 95% CI 3.6 to 16.6; P <0.001) and history of prior carotid endarterectomy or carotid artery stenting (OR 5.8, 95% CI 2.3 to 14.8; P <0.001) as significant predictors of sCBVD. CONCLUSIONS: Significant carotid artery stenosis is more likely in patients 65 years and older, presence of carotid bruit and prior CEA. On the other hand, it has low diagnostic yield in less than 65-year-old individuals, syncope and non-focal neurological symptoms. This highlights the need for better risk prediction models in order to promote optimal utilization.

Applying clinically proven human techniques for contraception and fertility to endangered species and zoo animals: a review.

Reversible contraception that does not alter natural behavior is a critical need for managing zoo populations. In addition to reversible contraception, other fertility techniques perfected in humans may be useful, such as in vitro fertilization (IVF) or oocyte and embryo banking for endangered species like amphibians and Mexican wolves (Canis lupus baileyi). Furthermore, the genetics of human fertility can give a better understanding of fertility in more exotic species. Collaborations were established to apply human fertility techniques to the captive population. Reversible vasectomy might be one solution for reversible contraception that does not alter behavior. Reversible approaches to vasectomy, avoiding secondary epididymal disruption, were attempted in South American bush dogs (Speothos venaticus), chimpanzees (Pan troglodytes), gorillas (Gorilla gorilla), Przewalski's horse (Equus przewalski poliakov), and Sika deer (Cervus nippon) in a variety of zoos around the world. These techniques were first perfected in > 4,000 humans before attempting them in zoo animals. In vitro fertilization with gestational surrogacy was used to attempt to break the vicious cycle of hand rearing of purebred orangutans, and egg and ovary vitrification in humans have led to successful gamete banking for Mexican wolves and disappearing amphibians. The study of the human Y chromosome has even explained a mechanism of extinction related to global climate change. The best results with vasectomy reversal (normal sperm counts, pregnancy, and live offspring) were obtained when the original vasectomy was performed "open-ended," so as to avoid pressure-induced epididymal disruption. The attempt at gestational surrogacy for orangutans failed because of severe male infertility and the lack of success with human ovarian hyperstimulation protocols. Vitrification of oocytes is already being employed for the Amphibian Ark Project and for Mexican wolves. Vasectomy can be a reversible contraception option in zoo animals, even in endangered species. Ongoing use of gamete and embryo freezing may salvage vanishing species.

Long-term outcomes of cardiac transplantation for peri-partum cardiomyopathy: a multiinstitutional analysis.

BACKGROUND: Outcomes of patients with a prior diagnosis of peri-partum cardiomyopathy (PPCM) undergoing heart transplantation are not well described but may be worse than for women who undergo transplantation for other etiologies. METHODS: Between 1999 and 2005, 69 women aged younger than 40 underwent transplantation for PPCM in 29 institutions participating in the Cardiac Transplant Research Database. Patients with PPCM were compared with 90 female recipients of similar age with idiopathic dilated cardiomyopathy (IDC) and history of pregnancy (P+), 53 with no prior pregnancy (P-), and with 459 men of a similar age with IDC. Rejection, infection, cardiac allograft vasculopathy, and survival were compared. RESULTS: Recipients with PPCM accounted for 1% of all transplants and 5% of transplants in women. Comparisons of the 4 patient groups were made. The risk of cumulative rejection was higher in the PPCM Group compared with the P- Group (p < 0.04) and the men (p < 0.0001). Cumulative risk of infection was lowest in the PPCM Group. Freedom from cardiac allograft vasculopathy was similar or higher in the PPCM Group compared with the other groups. Finally, the long-term survival of PPCM patients was comparable with the survival of men (p = 0.9), and there was a trend toward improved survival compared with the P+ Group (p = 0.07) and improved survival compared with the P- Group (p = 0.05). CONCLUSIONS: Heart transplantation for PPCM remains relatively infrequent. Survival and freedom from cardiac allograft vasculopathy in patients who receive a transplant for PPCM are no worse than in women who require a transplant for other indications, regardless of parity.

Report of the first U.S. patient successfully supported long term with the LionHeart completely implantable left ventricular assist device system.

We report our first successful long-term survivor in the United States with the LionHeart (Arrow International, Inc., Reading, PA) completely implantable left ventricular assist device system. The patient was initially deemed a poor candidate for cardiac transplantation and had inotrope-dependent, end-stage cardiac failure. The patient was supported for 13 months with this system. During this period of support, the patient returned to independent living and derived obvious benefits toward his daily activities with the completely implanted system. The device proved to be reliable during this period of support. Through lifestyle modification, the patient was ultimately deemed an appropriate candidate for heart transplantation and ultimately received successful transplantation.

Heart failure in women.

Congestive heart failure represents a growing health issue with significant morbidity, expense, and mortality. Unfortunately, despite heart failure affecting men and women equally, women historically have represented a minority in heart failure trials. Despite this disparity, treatment decisions rely heavily on these trials. Women with heart failure often have different clinical features than men, such as age of onset and comorbidities. Compared with men, women also demonstrate differences in remodeling and the response to injury, such as volume or pressure overload and myocardial infarction. We are only beginning to understand the clinical implications of these gender differences and their impact on pharmacologic treatments. After discussing these differences, a review of the agents useful in systolic failure is made, including angiotensin-converting enzyme inhibitors, b-blockers, digoxin, and aldosterone inhibition. Treatment of diastolic heart failure with empiric guidelines follows.

Biventricular pacing in congestive heart failure: a boost toward finer living.

With 550,000 new cases each year, congestive heart failure is a major medical problem. Several medical therapies, including digoxin, angiotensin-converting enzyme inhibitors, and beta-blockers, have reduced the number of re-hospitalizations and slowed the progression of congestive heart failure. Angiotensin-converting enzyme inhibitors, some beta-blockers, and the combination of hydralazine with nitrates have improved survival. Despite these benefits, medical therapy frequently fails to improve quality of life. Biventricular pacing has been introduced to resynchronize mechanical and electrical asynchrony frequently observed in patients with heart failure. The most recent pacing trials show an improvement in quality of life and functional class. Long-term data are needed to determine the effect of biventricular pacing on survival. The acute hemodynamic studies suggest that resynchronization pacing therapy may predict a positive long-term benefit for many patients with congestive heart failure.