Impact of Glucagon-Like Peptide 1 Receptor Agonists in Patients with Hemoglobin A1c of 9% or Greater.

Background: Glucagon-like peptide-1 receptor agonists (GLP-1 agonists) are effective hemoglobin A1c (HbA1c) and weight-lowering agents. The treatment effect is unknown in patients with HbA1c of 9% or greater. Objective: The purpose of this study was to evaluate glycemic control and weight loss after adding a GLP-1 agonist in patients with a baseline HbA1c of 9% (75 mmol/mol) or greater. Methods: A single-health system retrospective chart review screened adults with type 2 diabetes mellitus with a baseline hemoglobin A1c of 9% (75 mmol/mol) or greater and were prescribed a GLP-1 agonist for eligibility. The primary outcome assessed was the change in HbA1c from baseline to the first HbA1c check. Secondary outcomes included change in weight (kg) from baseline to the first HbA1c check. Results: Three hundred sixty-two patients were screened of which 151 (41.7%) were included in the final analysis. The mean change in HbA1c from baseline to first HbA1c check for all participants was -2.1% (95% CI: -2.3% to -1.8%; P < .001; -23 mmol/mol [95% CI: -25 to -20 mmol/mol]). The mean change in weight from baseline to first HbA1c check was -2.0 kg (95% CI: -2.6 kg to -1.4 kg; P < .001). Conclusion: In patients with type 2 diabetes mellitus with a baseline HbA1c ≥ 9%, GLP-1 agonist initiation resulted in a significant reduction of both HbA1c and weight compared to baseline. Large, prospective, multisite studies are needed to confirm findings of this retrospective study.

Leisure Possibilities of Adults Experiencing Poverty: A Community-Based Participatory Study.

Background. Poverty disproportionally affects persons with disabilities, elderly individuals and racialized groups. Leisure, play and rest are not prioritized in either services for or research with people living in poverty. Purpose. This study aims to examine the facilitators and barriers to participation in meaningful leisure activities for adults living in poverty. Method. We used community-based participatory research and art-based elicitation strategies with 39 service users at a food security organization. Findings. Individuals experiencing poverty value and engage in a variety of free and affordable leisure activities, but they are not afforded the necessary leisure opportunities, accommodations and supports as the general population. We co-created a map of local leisure resources to foster collective capacity in leisure planning, and to support organizations working with this population. Implications. Occupational therapists can work alongside members of underserved communities to uncover and address the systemic and local contextual barriers to engagement in leisure activities.

Off-label versus on-label prescribing of oral oncology agents on time to receipt of medication in patients with soft tissue sarcoma.

PURPOSE: Off-label prescribing of oral oncology agents has been explored in the treatment of soft tissue sarcoma. The time for a prior authorization approval or rejection for an off-label use can be lengthy. The purpose of this study is to capture this burden by comparing the time it takes for patients to receive off-label versus on-label treatment for their soft tissue sarcoma. PATIENTS AND METHODS: In this retrospective chart review study, patients aged 18 and older who received a new prescription for an oral oncology agent for soft tissue sarcoma from one of three sarcoma providers at Oregon Health & Science University oncology clinics between March 2014 and February 2016 were included. Objectives included comparing the effect of off-label to on-label prescribing of oral oncology agents on time to receipt of medication and patient copays for a 30-day supply of oral chemotherapy agent(s). RESULTS: The time to receipt of medication (median (IQR)) for the off-label group (N = 26) was 12.5 (3.3 to 30.8) days compared to the on-label group (N = 29), which was 8.0 (4.0 to 15.0) days (p = 0.327). The patient cost was $0.00 ($0.00 to $20.00) for the off-label group (N = 18) compared to $3.00 ($0.00 to $68.80) for the on-label group (N = 18) (p = 0.467). CONCLUSIONS: There were no differences in the time to receipt of medication or patient cost between off-label and on-label prescriptions in soft tissue sarcoma patients. Despite lack of statistical significance, these results are meaningful to patient care and require further study to investigate these findings.

Total intravenous anesthesia vs inhaled anesthetic for intraoperative visualization during endoscopic sinus surgery: a double blind randomized controlled trial.

BACKGROUND: Bleeding during endoscopic sinus surgery (ESS) can impair visualization and delay surgical progress. The role that anesthetic technique may have on the quality of surgical field during ESS has been previously studied. However, meta-analyses have deemed the current literature inconclusive and lacking methodological consistency. This study was designed with these critiques in mind to assess the effect of total intravenous anesthesia (TIVA) vs inhaled anesthetic on the quality of the surgical field during ESS. METHODS: This study was a double-blind, randomized, controlled trial of 30 patients of American Society of Anesthesiologists (ASA) class 1 or 2 undergoing bilateral ESS for the primary diagnosis of chronic rhinosinusitis. In addition to standard techniques to minimize blood loss, study patients were randomized to maintenance anesthesia with intravenous propofol or inhaled desflurane. Anesthetic depth was standardized using bispectral index (BIS). The primary outcome measured was the Wormald grading scale to assess the endoscopic surgical field. RESULTS: The use of TIVA was associated with a statistically significant reduction in mean Wormald score compared to desflurane (4.21 vs 5.53, p = 0.024). Mean Boezaart score was also lower in the TIVA arm (2.18 vs 2.76, p = 0.034). Experimental groups were homogeneous in all compared baseline characteristics. Secondary outcomes including surgical duration, time to extubation, and estimated blood loss were not found to be statistically significant between experimental groups. CONCLUSION: Even with all other factors implemented to optimize the surgical field, utilization of TIVA vs inhaled anesthetic still resulted in a statistically significant improvement in surgical field during ESS.

A dentin-derived hydrogel bioink for 3D bioprinting of cell laden scaffolds for regenerative dentistry.

Recent studies in tissue engineering have adopted extracellular matrix (ECM) derived scaffolds as natural and cytocompatible microenvironments for tissue regeneration. The dentin matrix, specifically, has been shown to be associated with a host of soluble and insoluble signaling molecules that can promote odontogenesis. Here, we have developed a novel bioink, blending printable alginate (3% w/v) hydrogels with the soluble and insoluble fractions of the dentin matrix. We have optimized the printing parameters and the concentrations of the individual components of the bioink for print accuracy, cell viability and odontogenic potential. We find that, while viscosity, and hence printability of the bioinks, was greater in the formulations containing higher concentrations of alginate, a higher proportion of insoluble dentin matrix proteins significantly improved cell viability; where a 1:1 ratio of alginate and dentin (1:1 Alg-Dent) was most suitable. We further demonstrate high retention of the soluble dentin molecules within the 1:1 Alg-Dent hydrogel blends, evidencing renewed interactions between these molecules and the dentin matrix post crosslinking. Moreover, at concentrations of 100 µg ml-1, these soluble dentin molecules significantly enhanced odontogenic differentiation of stem cells from the apical papilla encapsulated in bioprinted hydrogels. In summary, the proposed novel bioinks have demonstrable cytocompatibility and natural odontogenic capacity, which can be a used to reproducibly fabricate scaffolds with complex three-dimensional microarchitectures for regenerative dentistry in the future.

Retrospective analysis of pharmacist interventions in an ambulatory palliative care practice.

BACKGROUND: We have previously reported the development of an outpatient palliative care practice under pharmacist-physician collaboration. The Doris A. Howell Service at the University of California, San Diego Moores Cancer Center includes two pharmacists who participate in a transdisciplinary clinic and provide follow-up care to patients. OBJECTIVE: This study evaluated pharmacist interventions and patient outcomes of a pharmacist-led outpatient palliative care practice. METHODS: This was a retrospective data analysis conducted at a single, academic, comprehensive cancer center. New (first visit) patient consultations were referred by an oncologist or hematologist to an outpatient palliative care practice. A pharmacist evaluated the patient at the first visit and at follow-up (second, third, and fourth visits). Medication problems identified, medication changes made, and changes in pain scores were assessed. RESULTS: Eighty-four new and 135 follow-up patient visits with the pharmacist occurred from March 2011 to March 2012. All new patients (n = 80) were mostly women (n = 44), had localized disease (n = 42), a gastrointestinal cancer type (n = 21), and were on a long-acting (n = 61) and short-acting (n = 70) opioid. A lack of medication efficacy was the most common problem for symptoms of pain, constipation, and nausea/vomiting that was identified by the pharmacist at all visits. A change in pain medication dose and initiation of a new medication for constipation and nausea/vomiting were the most common interventions by the pharmacist. A statistically significant change in pain score was observed for the third visit, but not for the second and fourth visits. CONCLUSIONS: A pharmacist-led outpatient palliative care practice identified medication problems for management of pain, constipation, and nausea/vomiting. Medication changes involved a change in dose and/or initiating a new medication. Trends were observed in improvement and stabilization of pain over subsequent clinic visits.

Hybrid approach for treatment of behind the knee popliteal artery aneurysms.

We describe herein a combined approach to the treatment of popliteal artery aneurysms (PAA) that averts extensive dissections and potential blood loss particularly in cases of behind-the-knee aneurysms. Over the last 4 years, 13 patients (12 males) with mean age of 75 +/- 8 years were treated for PAAs at our institution with a combined surgical and endovascular approach. The mean size of popliteal aneurysms was 2.9 cm +/- 1.7 cm. One of the 13 cases (8%) was performed for acute ischemia and an additional 5 (38%) for claudication. All operations were performed under general anesthesia in supine position. Vein conduits (eight ipsilateral great saphenous veins, two contralateral great saphenous veins and one arm vein) were utilized for 11 bypasses. Of these, eight were from superficial femoral artery (SFA) to below the knee popliteal artery, two popliteal to popliteal and one SFA to posterior tibial artery. In addition, two expanded polytetrafluoroethylene femoral popliteal bypasses were performed. The distal anastomosis was performed after the popliteal artery was ligated distal to the aneurysm. Next, coil embolization of the aneurysmal sac was performed under fluoroscopic or ultrasound guidance. Coils were embolized through a 5F sheath. Lastly, the popliteal artery was ligated distal to the proximal anastomosis. Completion studies were obtained with duplex in six cases and arteriography in the remaining five cases. Mean follow-up was 11.6 months +/- 9.6. One bypass occluded in 2 months after surgery. One patient demonstrated continued growth of his aneurysm despite coil embolization twice and underwent an open ligation of the branches perfusing the aneurysm from within the sac through a posterior approach. This approach may be particularly useful for PAAs located behind the knee where optimal surgical exposure is often difficult and the collateral circulation is abundant. The proposed technique is simple, effective and averts extensive dissections required to minimize blood loss.

Use of the StarClose device for closure of inadvertent subclavian artery punctures.

PURPOSE: The placement of central catheters is a common procedure. It is also associated with multiple known complications. One of the potential complications that carry high morbidity and morality is arterial puncture and cannulation. Herein, we describe five case reports of a central line that was inadvertently placed in the subclavian artery and successfully removed using a StarClose device (Abbott Laboratories, Redwood CA). METHODS/RESULTS: A retrospective chart review of a prospectively maintained database was performed. We identified five cases of inadvertent subclavian artery cannulation during central venous catheter placement. All catheters were removed successfully either in the operating room under fluoroscopic guidance or at the bedside with closure of the arteriotomy using the StarClose device. No cases required conversion to an open procedure for repair. No postremoval hematomas, bleeding episodes, myocardial infarctions, arrhythmias, or adverse clinical sequelae were identified. DISCUSSION: Based on our limited experience, we feel that this method can be performed safely and expeditiously not only in the operating room but also at the bedside.

Bilateral internal iliac artery aneurysm infected with Campylobacter fetus.

This is a case report of a patient with Campylobacter fetus involving bilateral internal iliac artery aneurysms. The patient was treated successfully by ligation of the bilateral iliac artery aneurysms and antibiotics. According to a review of the English-language medical literature, this was the first such patient to be reported. A 69-year-old African-American male presented with a past medical history of repair of a 6.6 cm abdominal aortic aneurysm. It had been repaired with a Dacron bifurcated graft in July 2005. The bilateral internal iliac artery aneurysms (right 2.3 cm and left 3.4 cm) were coil embolized intraoperatively. The patient's past medical history was significant for hypertension and coronary artery disease and was status post-stent placement. He re-presented with fever and chills for 8 days in duration at home in March 2007. His fever was 101 to 102 degrees F. He denied vomiting, diarrhea, and a history of recent travel. The patient was admitted to the hospital for a fever workup. After an extensive workup, a left internal iliac artery aneurysm was found to be the source of sepsis. The patient was taken to the operating room for excision of the left internal iliac artery. No purulence was noted, but tissue overlying the aneurysm was thickened and fibrotic. Multiple cultures were taken. The tissue culture came back as C. fetus. Incidentally, the patient's preoperative computed tomographic scan revealed a right internal iliac artery aneurysm that was 4.2 cm on March 28, 2007, and 4.9 cm on April 23, 2007. Postoperatively, the patient's right internal iliac artery aneurysm was noted to be rapidly growing. He was promptly taken to the operating room for ligation of the right internal iliac artery aneurysm. The patient's postoperative course was unremarkable. He was discharged on ciprofloxacin for 14 days.

Superior vena cava perforation following the placement of a superior vena cava filter in males less than 60 years of age.

Although the utility of the superior vena cava (SVC) filter remains controversial, the safety and efficacy of SVC filters in patients with upper extremity deep venous thrombosis in whom anticoagulation is contraindicated or ineffective have been well described. However, few complications have been reported. Herein we describe a series of three cases of SVC perforation in three young males following the placement of SVC filters. All three patients had deep venous thrombosis on upper extremity duplex ultrasonography and contraindication to anticoagulation (n = 1) or failure of anticoagulation (n = 2). Cardiac tamponade was demonstrated on transthoracic echocardiography in all three cases. The pericardial effusion was evacuated with either median sternotomy or pericardiocentesis in two cases. One of the patients died of cardiac arrest, and an autopsy showed aortic perforation in addition to the SVC perforation. This patient underwent chest compression following the cardiac arrest. One patient was lost to follow-up, and the other patient remained asymptomatic at the 1-year follow-up. This is the first case of SVC perforation that is associated with aortic perforation after the placement of an SVC filter. Owing to this occurrence, one has to be aware of these life-threatening complications when placing an SVC filter, especially in males less than 60 years of age.

219 vascular fellows' perception of the future of vascular surgery.

In an attempt to identify the fellows' concerns about the future of the field of vascular surgery, we conducted a survey consisting of 22 questions at an annual national meeting in March from 2004 to 2007. In order to obtain accurate data, all surveys were kept anonymous. The fellows were asked (1) what type of practice they anticipated they would be in, (2) what the new training paradigm for fellows should be, (3) to assess their expectation of the needed manpower with respect to the demand for vascular surgeons, (4) what were major threats to the future of vascular surgery, (5) whether they had heard of and were in favor of the American Board of Vascular Surgery (ABVS), (6) who should be able to obtain vascular privileges, and (7) about their interest in an association for vascular surgical trainees. Of 273 attendees, 219 (80%) completed the survey. Males made up 87% of those surveyed, and 60% were between the ages of 31 and 35 years. Second-year fellows made up 82% of those surveyed. Those expecting to join a private, academic, or mixed practice made up 35%, 28%, and 20% of the respondents, respectively, with 71% anticipating entering a 100% vascular practice. Forty percent felt that 5 years of general surgery with 2 years of vascular surgery should be the training paradigm, while 45% suggested 3 and 3 years, respectively. A majority, 79%, felt that future demand would exceed the available manpower, while 17% suggested that manpower would meet demand. The major challenges to the future of vascular surgery were felt to be competition from cardiology (82%) or radiology (30%) and lack of an independent board (29%). Seventeen percent were not aware of the ABVS, and only 2% were against it; 71% suggested that vascular privileges be restricted to board-certified vascular surgeons. Seventy-six percent were interested in forming an association for vascular trainees to address the issues of the future job market (67%), endovascular training during fellowship (56%), increasing focus on the vascular fellows at national meetings (49%), and representation for the fellows on the national councils (37%). This survey suggests that several significant issues exist in the minds of vascular trainees that have not been addressed and may present opportunities for further dialogue.

Long-term follow-up for superior vena cava filter placement.

The short-term effectiveness and safety placement of superior vena cava (SVC) filter in the treatment of upper extremity deep venous thrombosis in patients with contraindication to anticoagulation have been well documented. However, as opposed to the numerous reported experiences with inferior vena cava filter placement and its complications, there has been no documented long-term follow-up on SVC filter placement. We, therefore, reviewed our experience with SVC filter placement. A retrospective review was performed of the 154 cases of patients who underwent SVC filter placement between January 1994 and August 2005 at our institution. Seven additional patients had unsuccessful SVC filter placement due to widespread deep venous thrombosis. The data were evaluated for both insertion complications (pneumothorax, hemorrhage, filter misplacement) and long-term complications (pulmonary embolism, migration, caval occlusion). The follow-up included review of serial chest radiographs to evaluate for filter migration in patients who lived at least 60 days after filter insertion and had chest radiography performed (n = 40), patients' charts, clinic visits, and telephone contacts, hospital databases, city death records, and national databases. There were 69 males and 85 females with a mean age of 73.6 years (range, 16-96 years; +/-15.3 [SD] years). Follow-up ranged from 1 day to 3750 days (256.3 +/- 576 days [mean +/- SD]) and 5 patients were lost to follow-up. Of the 154 patients, 58 survived longer than 60 days with mean follow-up of 628.4 days. All SVC filters (TrapEase, n = 38; Greenfield, n = 116) were successfully deployed in the 154 patients. During the follow-up, 114 (74.0% mortality) of the patients died of chronic illness or from cancer complications. There were three cases of pericardial tamponade (1.9%), and one case of misplaced filter in innominate vein. There were no known cases of symptomatic pulmonary embolism, caval occlusion, pneumothorax, or filter migration. SVC filter placement is associated with a low incidence of complications with long-term follow-up. These data help to reaffirm the safety and effectiveness of SVC filter placement. However, SVC perforation in young males remains a significant issue.

Limitations of and lessons learned from clinical experience of 1,020 duplex arteriography.

OBJECTIVE: Due to the inherent risks, deficiencies and cost associated with contrast arteriography (CA), our group has been utitilizing duplex arteriography (DA) for evaluating the arteries of the lower extremity for patients undergoing lower extremity revascularization. In an effort to further explore the strengths and weaknesses of DA, we reviewed our evolving experience with DA from January 1, 1998, to January 1, 2005. PATIENTS AND METHODS: The arterial segments starting from mid-abdominal aorta to the pedal arteries were studied in cross-sectional and longitudinal planes using a variety of scanheads of 7-4, 10-5, 12-5, 5-2 and 3-2 MHz extended operative frequency range to obtain high-quality B-mode, color and power Doppler images as well as velocity spectra. In 906 patients, 1,020 duplex arteriograms were obtained. The ages ranged from 30-98 years old with a mean of 73+/-11 (SD) years. Fifty percent of the patients were diabetics. Indications for the examination included: tissue loss (409), rest pain (221), claudication (310), acute ischemia (74), popliteal aneurysm (45), SFA aneurysm (2), abdominal aortic aneurysms (AAA) (10) and failing bypass (55). Prior procedures had been performed in 262. DA was performed by six technologists (4 of whom are MDs). In all, 207 DA were performed intraoperatively and the remainder, preoperatively. RESULTS: The resultant procedures based upon DA included: bypass to the popliteal artery (262) and bypass to an infrapopliteal artery (325), endovascular procedures (363), thrombectomy (11), embolectomy (9), inflow bypass procedures to the femoral arteries (46), débridment (4), amputation (8) and no intervention (75). The areas not visualized well included: iliac (73), femoral (26), popliteal (17), and infrapopliteal (221). Additional imaging after DA was deemed necessary in 102 cases to obtain enough information to plan lower extremity revascularization. Factors associated with increased need to obtain CA included: DM (p<.001), infrapopliteal calcification (p<.001), older age (p = .01) and limb threatening ischemia (p<.001). Factors not associated with the need to obtain CA included: which technologist performed the exam, whether the technologist has a medical degree and whether the patient underwent prior revascularization. CONCLUSIONS: In 90% of patients reviewed, DA is able to obtain the needed information to plan lower extremity revascularization. Severe tibial vessel calcification is the most common cause of an incomplete DA exam and determines when alternative imaging modalities need to be obtained.

Effect of Duplex Arteriography in the Management of Acute Limb-Threatening Ischemia From Thrombosed Popliteal Aneurysms.

The role of routine use of duplex arteriography to diagnose thrombosis of popliteal artery aneurysm as a cause of acute lower extremity ischemia is investigated. In all, 109 patients (group 1) from 1994 to 1997 and 201 patients from 1998 to 2001(group 2) presenting with acute limb-threatening ischemia were studied. None of the group 1 patients underwent preoperative duplex arteriography, and no diagnosis of acute popliteal artery aneurysm thrombosis was made. Ten patients with acute ischemia due to thrombosed popliteal artery aneurysm were identified in group 2 when preoperative duplex arteriography was routinely performed. Urgent revascularization was performed based on the results of duplex arteriography. Six patients had functioning bypasses with a mean follow-up of 15.6 months. There were 3 deaths, 2 within 30 days and 1 after 2(1/2) years with functioning grafts. One patient was lost to follow-up. Routine use of duplex arteriography may provide the diagnosis and may identify the available outflow vessels for popliteal artery aneurysm.

Predictive factors of femoropopliteal patency after suboptimal duplex-guided balloon angioplasty and stenting: is recoil a bad sign?

Currently, the value of stenting during femoropopliteal balloon angioplasty (FPBA) remains unclear. Herein we evaluate the patency rates of successful duplex-guided balloon angioplasty (DAGBA) alone versus suboptimal DAGBA followed by stenting and the prestenting dissection versus recoil as potential indicators of stent success or failure. Over a period of 27 months, we performed 291 duplex-guided FPBAs (194 stenoses; 97 occlusions) on 244 limbs in 220 patients. Disabling claudication was the indication in 67%. Critical limb ischemia was the indication in the remaining 33%. Self-expanding nitinol stents were used when plaque dissection and/ or recoil caused diameter reduction > or = 40%. Serial follow-up duplex scans were obtained. Severe restenosis (> 70%) was measured by B-mode imaging and a peak systolic velocity ratio > 3. Follow-up ranged from 1 to 41 months (mean 10 +/- 8.3 months). The overall mean interval for restenosis and occlusion was 6.5 +/- 4.2 months and 5.6 +/- 6.1 months, respectively. Stents did affect overall patency results compared with not using stents. Reasons for stenting were plaque recoil, dissection, or both in 98 (53%), 44 (24%), and 42 (23%) cases, respectively. Six-month patency was 59%, 94%, and 69%, respectively. The difference between plaque recoil and dissection was significant (p<.04). The use of stents during FPBA may be associated with balloon angioplasty site failure in the femoropopliteal segment. To our knowledge, this is the first report ever to document plaque recoil as a predictor of balloon angioplasty site failure notwithstanding stent placement.