Get With the PROGRAM: A Guide to Compassionate Communication.

Despite growing interest in the importance of compassionate communication and patient experience, many physicians still feel unprepared when faced with delivering bad medical news. To address this need, few methods have been developed to offer physicians a structure for these conversations, with the goal of making the dialogues less traumatic for patients and families and less stressful for physicians. The PROGRAM method promotes compassionate communication to help physicians make a connection with their patients, which is central to improving health care quality. The objective of this article is to provide a systemic approach to structuring difficult dialogues with patients and their families.

Predictors of inpatient outcomes in hospitalized patients after left heart catheterization.

Clinical and laboratory factors predicting inpatient outcomes, specifically in-hospital mortality and length of stay (LOS), have not been defined for hospitalized patients specifically referred for left heart catheterization and coronary angiography (LHC). The objective of the study was to determine these outcomes and their predictors in hospitalized patients after LHC. Multivariate logistic regression models were used to identify risk factors for in-hospital mortality and Cox proportional hazards models were used to identify factors determining LOS in 9,420 consecutive patients hospitalized for LHC. Odds ratio for in-hospital mortality and hazard ratio for prolonged LOS were derived. The strongest predictors of mortality were advanced age, left ventricular (LV) end-diastolic pressure (EDP), LV ejection fraction (EF), systemic blood pressure, and renal insufficiency. Predictors of prolonged LOS were LVEDP, LVEF, 3-vessel coronary artery disease, and valvular disease. Clinical and laboratory characteristics of patients with an LVEF > or =50% were also compared with those of patients with an LVEF <50%. Predictors of mortality and LOS remained the same for patients with an LVEF <50%. For an LVEF > or =50%, LVEDP also determined LOS and chronic renal insufficiency provided predictive power to mortality and LOS in this subgroup. In conclusion, several readily attainable clinical and laboratory parameters predict inpatient mortality and LOS in hospitalized patients referred for LHC.

Predicting patient volume in cardiac catheterization laboratory to improve resource management.

Using historical data within the Information Warehouse of the Ohio State University Medical Center, prediction on daily patient volume to catheterization laboratory was attempted to facilitate resource management and planning.

Drug eluting stent implantation for the treatment of symptomatic myocardial bridging is associated with favorable peri-procedural results and short-term outcomes.

Myocardial bridging is the most common congenital coronary abnormality, and is frequently found on post-mortem cardiac examination. Although often asymptomatic, clinical presentation can vary from unstable angina to sudden cardiac death. Only isolated cases of using drug eluting stents (DES) for bridging segments have been described. Our objective was to retrospectively analyze a series of patients undergoing percutaneous coronary intervention (PCI) with DES for symptomatic myocardial bridging and follow post-procedure outcomes. Results revealed favorable peri-procedural angiographic and short-term clinical results with DES implantation. Although initial data regarding DES implantation for symptomatic myocardial bridging are promising, long-term follow up, particularly related to in-stent restenosis will be important.

Inhibition of ribonucleotide reductase reduces neointimal formation following balloon injury.

Percutaneous transluminal coronary angioplasty (PTCA) has greatly benefited patients with occluded coronary arteries, but its benefits have been undermined by a high incidence of restenosis. The introduction of coronary stents has significantly improved the short and long term outcome but restenosis still occurs in approximately 15 to 30% of patients within 6 months. Research efforts are now being directed toward combination stenting and drug delivery. Among the therapeutic targets being pursued are agents that can impede smooth muscle cell migration and proliferation, as these processes are critical components of restenosis injury. We propose that inhibiting the conversion of ribonucleotides to deoxyribonucleotides will impede cell proliferation and, as such, limit the degree of restenosis. Therefore, we tested whether the potent ribonucleotide reductase inhibitors Didox (3,4-dihydroxybenzohydraxamic acid) and Imidate (ethyl-3,4,5-hydroxybenzimidate) can limit the neointimal proliferation associated with restenosis using a rat carotid model of balloon dilatation injury. Results demonstrated that both Didox and Imidate significantly reduced intimal thickening, resulting in a 71 and 62% decrease in the intima/media ratio, respectively. Similar efficacy was seen with the commercially available ribonucleotide reductase inhibitor hydroxyurea, demonstrating the importance of this enzyme in vascular remodeling. Results from cell proliferation studies suggest that the mechanism of protection is inhibition of smooth muscle cell (SMC) proliferation. In addition, Didox and Imidate (100 microM) are potent inhibitors of SMC migration, which may also contribute to their vascular protective effects. These results suggest that inhibition of ribonucleotide reductase may provide a potent strategy to prevent post-PTCA restenosis.

Advancing immunosuppression therapy to counter the progression of cardiac allograft vasculopathy.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is the major cause of late mortality in heart transplant recipients. Because immunosuppressive therapy has been convincingly shown to suppress cellular rejection and prolong cardiac allograft survival, we assessed the efficacy of advancing immunosuppressive therapy in reversing or delaying CAV by switching azathioprine to combination mycophenolate mofetil and prednisone (MMF-P). METHODS AND RESULTS: Seventeen adult posttransplant patients, whose CAV was prospectively approached with the MMF-P protocol, were studied. The development of significant CAV was declared on the index coronary angiogram and the MMF-P protocol was instituted. The degree of occlusion for all coronary lesions was quantitated for the index angiogram, and for the angiograms performed 1 year before (baseline) the index angiogram and annually for 2 years after the index angiogram (MMF-P years 1 and 2). There was a significant change in percent occlusion over time (P < .001). Percent occlusion increased significantly from the baseline year to the index CAV year, but then decreased significantly from the index CAV year to the MMF-P treatment years 1 and 2. CONCLUSION: Advancing immunosuppression with MMF-P can delay the progression of and partially reverse lumen narrowing of CAV in heart transplant recipients.