Brandon R. Porten

Hyperbaric Oxygen Treatment Outcome for Different Indications from a Single Center

BACKGROUND Hyperbaric oxygen (HBO) is used as an adjunctive therapy for a variety of indications. However, there is a lack of high-quality research evaluating HBO treatment outcomes for different indications available in the current literature. METHODS We retrospectively reviewed all patients who underwent HBO therapy at a single hyperbaric center from January 2010 to December 2013 using predetermined criteria to analyze successful, improved, or failed treatment outcomes for the following indications: chronic refractory osteomyelitis, diabetic foot ulcer, failed flap or skin graft, osteoradionecrosis, soft tissue radiation necrosis, and multiple coexisting indications. RESULTS Among the included 181 patients treated with adjunctive HBO at our center, 81.8% had either successful or improved treatment outcomes. A successful or improved outcome was observed in 82.6% of patients treated for chronic refractory osteomyelitis (n = 23), 74.1% for diabetic foot ulcer (n = 27), 75.7% for failed flap or skin graft (n = 33), 95.7% for osteoradionecrosis (n = 23), 88.1% for soft tissue radiation necrosis (n = 42), and 72.4% for multiple coexisting indications (n = 29). Among 4 patients treated for other indications, 100% of the cases were either successful or improved. CONCLUSIONS This study has provided a comprehensive outcome survey of using HBO for the previously mentioned indications at our center. It supplements the literature with more evidence to support the consideration of HBO in different indications.

Real-Time Decision Support to Guide Percutaneous Coronary Intervention Bleeding Avoidance Strategies Effectively Changes Practice Patterns

Approximately 600 000 percutaneous coronary interventions (PCIs) are performed annually in the United States.1 Periprocedural bleeding is a common complication of PCI,2–6 occurring in 2% to 6% of cases.6–12 Bleeding is associated with major adverse events, including short- and long-term mortality,4,8–11,13 as well as prolonged hospital length of stay (LOS)7–10,14 and higher hospital costs.6,7,15,16 Periprocedural bleeding seems to be predictable and modifiable.4 A validated risk prediction algorithm may help clinicians estimate bleeding risk in patients undergoing PCI, and established bleeding avoidance strategies (BAS), such as bivalirudin, radial artery access, and vascular closure devices, have been demonstrated to reduce bleeding.2,16–24 However, recent studies have reported that patients at highest risk for bleeding are least likely to receive treatment with BAS.2,5 Accurate preprocedure bleeding risk assessment scoring may provide a significant opportunity for physicians to selectively use effective preventative tactics in patients most likely to benefit and improve PCI safety, care quality, and subsequently hospitalization costs. Bleeding events after cardiovascular procedures have been identified by the Centers for Medicare and Medicaid Services to be quality indicators among centers participating in its Acute Care Episode demonstration.2 However, data on the impact of pre-PCI bleeding risk assessment on physician practice patterns, BAS use, and quality outcomes are sparse. We developed a quality improvement program for PCI patients using a preprocedure bleeding risk score to stimulate the use of consensus BAS in high-risk, high-cost patients. The specific aims of the program were to improve patient safety and care quality and to decrease LOS and hospital costs by reducing bleeding events and associated complications in PCI patients. An interdisciplinary team …

Postpartum reversible cerebral vasoconstriction syndrome: review and analysis of the current data.

Postpartum reversible cerebral vasoconstriction syndrome (PPRCVS) is a rare but serious cause of headache that occurs in the early postpartum period. The rarity of this disorder has limited the current literature to single case reports and small, observational case series. The lack of familiarity with PPRCVS may contribute to mismanagement of these unique patients and lead to poor outcomes. To address current gaps in the understanding of PPRCVS, this review and data analysis characterizes the demographics, presentation, clinical course, management and prognosis of PPRCVS and provides a general review of the epidemiology, pathophysiology and diagnosis to assist clinicians who may care for patients with this rare disorder.

Design, Challenges, and Implications of Quality Improvement Projects Using the Electronic Medical Record

Postoperative atrial fibrillation (POAF) is a frequent complication of cardiac surgery, which results in increased morbidity, mortality, length of stay, and hospital costs. We developed and followed a process map to implement a protocol to decrease POAF: (1) identify stakeholders and form a working committee, (2) formal literature and guideline review, (3) retrospective analysis of current institutional data, (4) data modeling to determine expected effects of change, (4) protocol development and implementation into the electronic medical record, and (5) ongoing review of data and protocol adjustment. Retrospective analysis demonstrated that POAF occurred in 29.8% of all cardiovascular surgery cases. Median length of stay was 2 days longer (P<0.001), and median total variable costs

Arterial Embolisms and Thrombosis in Upper Extremity Ischemia

2495 higher (P<0.001) in POAF patients. Modeling predicted that up to 60 cases of POAF and >

Challenges of Takayasu Arteritis in Pregnancy: A Case Report:

200 000 annually could be saved. A clinically based electronic medical record tool was implemented into the electronic medical record to aid preoperative clinic providers in identifying patients eligible for prophylactic amiodarone. Initial results during the 9-month period after implementation demonstrated a reduction in POAF in patients using the protocol, compared with those who qualified but did not receive amiodarone and those not evaluated (11.1% versus 38.7% and 38.8%; P=0.022); however, only 17.3% of patients used the protocol. A standardized methodological approach to quality improvement and electronic medical record integration has potential to significantly decrease the incidence of POAF, length of stay, and total variable cost in patients undergoing elective coronary artery bypass graft and valve surgeries. This framework for quality improvement interventions may be adapted to similar clinical problems beyond POAF.

Ehlers-Danlos Syndrome Type IV: A Case Report.

Objective: Upper extremity ischemia (UEI) is an uncommon condition that can lead to permanent disability. There is a limited understanding of the etiology, management, and outcomes of the disease. Methods: We retrospectively reviewed the charts of all patients who were diagnosed with “embolism and/or thrombosis of arteries of upper extremity” at our institution from January 2005 to December 2013. Results: Patients diagnosed with embolisms were older (P < .001), more likely to undergo thromboembolectomy (P < .001), had higher rates of hypertension (P = .001), and had longer lengths of hospital stay (P = .002). There were no significant differences in complications or mortality at 30 days and up to 1 year. Conclusion: At our center, embolism was found to be the most common etiology for UEI followed by thrombosis and stenosis. Patients presented with embolism were older, were more likely to undergo thromboembolectomy, and had higher rates of hypertension and longer hospital stays.

VASCULAR CLOSURE DEVICE USE IN HIGH BLEEDING RISK PATIENTS REDUCES PERI-PROCEDURAL COMPLICATIONS AND IMPROVES COSTS

Takayasu arteritis is a rare, chronic vasculitis of unknown etiology characterized by inflammation of the aorta and its main branches. Although Takayasu arteritis mostly affects women of childbearing age, there is a paucity in the literature on pregnancy associated with Takayasu arteritis. Pregnant patients are at increased risk of cardiovascular complications, including hypertension and congestive heart failure, which may jeopardize both maternal and fetal outcomes. Furthermore, optimal management has not yet been established for pregnant patients with Takayasu arteritis, posing a clinical challenge. We present a case of a young woman with Takayasu arteritis whose symptoms and disease activity improved during 2 pregnancies. Although her first pregnancy was complicated with preeclampsia, gestational diabetes, and preterm vaginal delivery, her second pregnancy was uneventful. This case provides a rare glimpse of Takayasu arteritis in pregnancy and highlights the challenges of medical management in gravid patients.

REAL TIME DECISION SUPPORT TO GUIDE PERCUTANEOUS CORONARY INTERVENTION BLEEDING AVOIDANCE STRATEGIES REDUCES PERI-PROCEDURAL COMPLICATIONS AND IMPROVES COSTS

Ehlers-Danlos syndrome (EDS) encompasses a group of rare genetic connective tissue disorders. The vascular type (type IV) poses the most serious risk to patients. Diagnosis is usually difficult, especially if patients lack a family history. Life-threatening vascular emergency such as dissection or rupture can be the first presenting symptom. Management of the disease can pose a clinical challenge due to the emergency of presentation, tissue friability, and lack of clear management recommendations. We report a unique case of a 40-year-old man who presented with a ruptured celiac artery and a strong family history of EDS. This case highlights the difficulties and complications associated with treating this uncommon and serious disease.

Why the Delay? Identification of Factors Which Delay Diagnosis of Acute Aortic Dissection

Bleeding is common in percutaneous coronary intervention (PCI) and increases length of stay (LOS), costs and mortality. Risk assessment scoring prior to PCI may enable physicians to selectively employ bleeding avoidance strategies such as vascular closure devices (VCD) to improve outcomes. We