Accelerated Wean: A Novel 3 Day Berlin Heart Protocol in a Pediatric Patient.

We present the case of a 4 year old child who developed cardiogenic shock due to permanent junctional reciprocating tachycardia, requiring left ventricular assist device (LVAD) support. Despite the initial critical clinical presentation, successful myocardial recovery was achieved over 5 months, allowing for successful LVAD explantation. The patient's young age and behavioral issues were constraining factors for a prolonged LVAD wean trial. A modified wean protocol over a 3 day period with parameters for assessment of cardiac recovery before LVAD explantation is described.

Perfusion techniques for an 800 g premature neonate undergoing Arterial Switch Procedure for Transposition of the Great Arteries☠.

Early cardiac surgery in neonates and infants with congenital heart disease has been performed since the middle to late years of the twentieth century. To date, there are very few reports of successful congenital heart surgery using cardiopulmonary bypass (CPB) in premature babies less than 1000 g with serious congenital heart disease. Limited information is available in the literature describing perfusion techniques for this extremely fragile patient population. Miniaturization of the CPB circuit contributes to multiple factors that affect this population significantly. These factors include the reduction of patient-to-circuit ratios, volume of distribution of pharmacological agents, management of pressure gradients within the CPB system, and increased tactile control by the attending perfusionist. Careful management of the physiological environment of the patient is of utmost importance and can mitigate risks during CPB, including volume shifts into the interstitial space, electrolyte, and acid-base imbalance, and intracranial hemorrhage. We report perfusion techniques successfully utilized during the surgical repair of transposition of the great arteries for an 800 g, 28-week-old neonate. CPB techniques for the smallest and youngest patients may be executed safely when proper physical, chemical, and perfusion process adjustments are made and managed meticulously.

A Novel Method to Safely De-Air a HeartWare System in a Single-Ventricle Patient by Utilizing ECMO and a Minimized CPB Circuit.

The survival of congenital heart disease (CHD) patients with single-ventricle (SV) physiology has markedly increased as a result of advances in operative techniques and postsurgical management. Nonetheless, these patients remain highly susceptible to end-stage heart failure requiring cardiac replacement therapies at early ages. Given a worldwide shortage of transplantable organs, mechanical circulatory support (MCS) represents an alternative treatment option. The significant heterogeneity of the SV population presents unique indications for MCS that have begun to be evaluated. This case study describes a 12-year-old female with heterotaxy syndrome and an SV condition, previously palliated with a Fontan operation at another institution. The patient was placed on veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) during prolonged cardiopulmonary resuscitation, and later underwent HeartWare ventricular assist device (HVAD) implantation as a bridge to transplantation (BTT). A novel method was chosen to optimize careful de-airing of the heart through a minimized cardiopulmonary bypass (CPB) setup, during full ECMO support and surgical insertion of the HeartWare. The ascending aorta was vented proximal to the HVAD outflow graft anastomosis through a minimized CPB circuit at <10% of the ECMO flow rate. This circuit adaption allowed for euvolemic resuscitation via connection from the minimized CPB circuit to the venous limb of the ECMO circuit. The transition from VA-ECMO to the HeartWare was well tolerated despite a challenging sternotomy and cardiac anomaly. A minimized bypass circuit proved efficacious for the benefit of volume resuscitation and safe de-airing of the HVAD while on ECMO support. The literature is limited concerning safe practices for implantation of durable VADs in complex SV patients coupled with those transitioning from varying modalities of MCS. As SV survivability regresses to heart failure, it is essential that we share techniques that aim to improve the long-term outcomes for successful BTT or bridge to decision (BTD).

Conceptual framework for assisted dying for individuals with dementia: Views of experts not opposed in principle.

Dementia is one of the prominent conditions for which an aging population has been seeking end-of-life solutions such as assisted dying. Individuals with dementia, however, are often unable to meet the eligibility criteria of being mentally competent and are thus discriminated against in relation to assisted dying laws. Provided that the assisted death directive is being made in sound mind, it is still of concern whether these advance directives can be appropriately framed and safeguarded to protect the wish of these vulnerable individuals while preventing harm. Therefore, to establish consensus views of experts on primary issues of, and concerns about, assisted dying for individuals with dementia as well as exploring tentative conceptual framework to safeguard practice and application, a three-round Delphi study was conducted. A core group of 12 experts from five countries was recruited comprising expertise in domains relevant to assisted dying and dementia. A semantic-thematic approach was applied to analyze the 119 generated statements. Evaluation of these research statements resulted in full consensus of 84 (70%) items. Our primary findings highlight seven core domains: applicability of assisted dying for dementia; ethical, practical, and pathological issues regarding the application of assisted dying; and ethical, legal, and professional recommendations for the ways forward. Despite the issues surrounding the provision of assisted death for individuals with dementia, our findings lead us to cautiously conclude that devising "adequate" safeguards is achievable. The result of this research may benefit future research and practice.

Determinants of Women's Sexual Dissatisfaction: Assessing a Cognitive-Emotional Model.

INTRODUCTION: Recent studies have demonstrated the role of sexual dysfunctional beliefs, negative automatic thoughts, and emotional responses in relation to sexual functioning. Nevertheless, no studies seem to have evaluated the role of these cognitive-emotional factors in determining sexual dissatisfaction. AIM: To test a cognitive-emotional model of sexual dissatisfaction in women. METHODS: In total, 207 women answered questionnaires assessing sexual dissatisfaction and cognitive and emotional variables that might affect sexual dissatisfaction. MAIN OUTCOME MEASURES: Sexual dissatisfaction was measured by the Index of Sexual Satisfaction, sexual beliefs were measured by the Sexual Dysfunctional Beliefs Questionnaire, and thoughts and emotional responses were measured by the Sexual Modes Questionnaire. RESULTS: A path analysis was conducted to assess the conceptual model proposed. Results indicated that dysfunctional sexual beliefs work as predisposing factors by eliciting negative automatic thoughts and emotions, which impair the processing of erotic stimuli and interfere negatively with sexual satisfaction. CONCLUSION: This finding suggests a role for cognitive and emotional factors in predisposing and maintaining sexual dissatisfaction in women, suggesting relevant implications for intervention.

Impact of an Alcohol Poisoning Storyline in a Fictional Television Program: An Experimental Study With a Live-to-Air Stimulus.

Storylines in fictional television programs may be an effective medium for health-promoting messages. This randomized pretest-posttest (N = 111) with follow-up (n = 71) study examined the persuasive impact of an alcohol poisoning story in the program ER on viewers' drinking-related beliefs, attitudes, intentions, and behavior. The perception of persuasive intent is theorized to be a key factor influencing a narrative's impact; therefore, this study also examined the influence of perceived persuasive intent on viewing outcomes. Viewing group participants were asked to view a specific upcoming episode of ER when it was first scheduled to air on national television in New Zealand. The results suggest that the alcohol poisoning story had a beneficial impact on viewers' drinking-related beliefs, attitudes, and intentions. Perceived persuasive intent was not a significant predictor of viewing outcomes. This study is the first randomized experiment that has used a live-to-air stimulus to examine the impact of a health-promoting storyline in a fictional television program that has been created and broadcast in a developed nation. The significant effects found at post-viewing and follow-up provide further empirical support to the existing experimental literature, with enhanced ecological validity, for the potential positive impact of health-promoting storylines in fictional television programs.

Misregulation of Rad50 expression in melanoma cells.

DNA double-strand breaks are increased in human melanoma tissue as detected by histone H2AX phosphorylation.(1-3) We investigated two of the downstream effectors of DNA double-strand breaks, Rad50 and 53BP1 (tumor suppressor p53 binding protein 1), to determine if they are altered in human primary melanoma cells. Melanoma cases showed high Rad50 staining (81.8%; 9/11) significantly more frequently than conventional or atypical melanocytic nevi (0%; 0/18). In contrast, the staining pattern for 53BP1 appears similar between melanoma and nevi. This is the first study that shows activation and misregulation of the DNA repair pathway in human melanoma cells. The staining features of Rad50, a component of an essential DNA double-strand break repair complex, are clearly increased in melanoma cells with regards to both staining intensity and the number of positive melanoma cells. Interestingly, among the melanoma cases with increased Rad50 staining, most demonstrated cytoplasmic rather than nuclear staining (88.9%, 8/9). Further studies are needed to determine the cause of this mislocalization and its affects, if any, on DNA double-strand break repair in melanoma.

Clinical and magnetic resonance imaging outcomes following platelet rich plasma injection for chronic midsubstance Achilles tendinopathy.

BACKGROUND: The successful treatment of chronic mid-substance Achilles tendinopathy remains elusive. Approximately 25% to 50% of patients fail conservative treatment modalities. Scientific evidence has supported the use of platelet rich plasma (PRP) in the tendon healing process, however despite initial promise there is a paucity of clinical data to validate a role for PRP in the treatment of tendon disorders including chronic midsubstance Achilles tendinopathy. METHODS: As an alternative to operative treatment, our practice offers patients with chronic midsubstance Achilles tendinopathy intratendinous injection of PRP. We retrospectively reviewed all patients treated for Achilles tendinopathy with PRP injection over a 2-year period. Baseline and post injection functional scores including the Foot and Ankle Ability Measure (FAAM), Foot and Ankle Ability Measure - Sports (FAAMS), and the Short Form health survey (SF-8) were examined. Patients also underwent post-injection magnetic resonance imaging (MRI), which were compared to available pre-injection MRI data. RESULTS: Ten patients were identified for this study. Pre- and postinjection functional outcome scores were available for eight of ten patients. The average SF-8 score improved from 24.9 to 30.0, the average FAAM score improved from 55.4 to 65.8, and the average FAAMS score improved from 14.8 to 17.4. Complete MRI data was available for six patients. Only one in six Achilles tendons demonstrated qualitative MRI improvement post-injection. CONCLUSION: Patients who received PRP injection demonstrated modest improvement in functional outcome measures, however MRI appearance of diseased Achilles tendons remained largely unchanged following PRP injection.

Salter-Harris type III fractures of the distal femur: plain radiographs can be deceptive.

BACKGROUND: Salter-Harris (SH) III fractures of the distal femur, although rare, can have devastating effects. The purposes of this study were to: (1) compare the intra-articular fracture displacement measured on plain x-ray and magnetic resonance imaging (MRI) or computed tomography (CT) scan and (2) report the outcomes of patients with a SH III fracture of the distal femur. METHODS: All SH III distal femur fractures treated at a large Children's Hospital with a Level I Pediatric Trauma Center between 1995 and 2006 were retrospectively reviewed. A total of 14 patients (average age: 13 y, 11 mo; range: 7 y, 8 mo to 17 y, 11 mo) with an average follow-up time of 21.50 months (range: 2 to 47 mo) were included in this study. Fracture displacement on plain x-ray was compared with the fracture displacement measured on MRI or CT scan. The average time between the initial plain x-ray and MRI or CT scan was 37.48 days (range: 3 h to 6 mo). RESULTS: Plain x-rays significantly underestimated the displacement of SH III fractures versus MRI or CT scan. Six patients who had both plain x-ray and MRI or CT scan had a measured displacement of 0.42 mm and 2.70 mm, respectively (paired Student t test, P=0.005). Ten of the 14 patients (71%) had no physical limitations and full knee motion at their most recent follow-up visit. The treatment of 4 patients (29%) was changed based on the findings of the additional MRI or CT scan. CONCLUSIONS: This study and earlier studies have shown a high rate of poor results with SH III fractures of the distal femur. This type of fracture pattern is extremely unstable and the true displacement is often underestimated by x-rays. Thus, it is strongly recommended that an MRI or CT scan be obtained on every SH III fracture of the distal femur. Moreover, any SH III fracture visible on plain radiographs should be treated with open reduction, internal fixation. LEVEL OF EVIDENCE: Level IV.

Domain structure elucidation of human decorin glycosaminoglycans.

The structure of the GAG (glycosaminoglycan) chain of recombinantly expressed decorin proteoglycan was examined using a combination of intact-chain analysis and domain compositional analysis. The GAG had a number-average molecular mass of 22 kDa as determined by PAGE. NMR spectroscopic analysis using two-dimensional correlation spectroscopy indicated that the ratio of glucuronic acid to iduronic acid in decorin peptidoglycan was 5 to 1. GAG domains terminated with a specific disaccharide obtained by enzymatic degradation of decorin GAG with highly specific endolytic and exolytic lyases were analysed by PAGE and further depolymerized with the enzymes. The disaccharide compositional profiles of the resulting domains were obtained using LC with mass spectrometric and photometric detection and compared with that of the polysaccharide. The information obtained through the disaccharide compositional profiling was combined with the NMR and PAGE data to construct a map of the decorin GAG sequence motifs.

Low incidence of postoperative complications due to pin placement in computer-navigated total knee arthroplasty.

Computer-navigated joint arthroplasty surgery using optical tracking systems requires arrays fixated to bone via pins. Reports of fractures at pin sites have raised concern about safety. We reviewed the postoperative complications occurring in a single-surgeon series of 984 consecutive primary total knee arthroplasties. All pins were placed unicortically and connected by a dual pin array. Femoral pins were placed into the medial epicondyle, and tibial pins were placed in the shaft 10 cm inferior to the joint line. There were no fractures. Seventeen (1.7%) patients had minor pin-related complications. Twelve patients had a superficial infection around the tibial pin sites, which resolved with antibiotics. None of the infections required readmission or reoperation. We believe pin placement to be safe and effective with proper technique.

Endovascular radiofrequency obliteration using 90 degrees C for treatment of great saphenous vein.

The recommended treatment temperature for endovascular radiofrequency obliteration (RFO) of the great saphenous vein (GSV) is 85 degrees C. Faster catheter pullback rates are possible when the operating catheter tip temperature is increased. We studied the safety and effectiveness of RFO of the GSV using a temperature of 90 degrees C, tumescent infiltration, and catheter pullback rates double the current standard. Sixty-eight patients (85 limbs) with ultrasound-documented saphenofemoral valve reflux underwent Closure procedure. Treatment temperature was increased to 90 degrees C, and pullback times were increased to 5-6 cm/min. Outcome measures were occlusion of treated vein segments at 3 days and 6 months postoperatively and clinical evaluation of complications at 3 days and 6 months postoperatively. At 3 days, 96% (80/83) of GSVs were occluded and at 6 months 90% (66/73) were occluded. At 3 days and 6 months, no limbs had evidence of deep venous thrombosis or skin burns. Pullback times were shortened from 15-18 min to 8 min. Closure procedure of the GSV using 90 degrees C and faster catheter pullback rates occluded a refluxing GSV with similar 3-day and 6-month occlusion rates as 85 degrees C.