Benefis Health System Foundation

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited renal disorder. ADPKD is not only associated with progression of renal disease, but also several hepatobiliary manifestations. This report is of a 49-year-old female with recurrent cholelithiasis and cholecystitis following subtotal cholecystectomy in the context of aberrant biliary anatomy and ADPKD. There were significant adhesions obscuring the cystic duct, necessitating the second cholecystectomy be performed open. The right posterior hepatic duct was adhered to the gallbladder wall and was perforated while attempting to remove the gallbladder remnant. The duct was repaired over a T-tube, without any subsequent biliary leak. The cystic duct was hugely dilated and impacted with stones down to the junction with the common bile duct, which were evacuated, and the cystic duct was oversewn along with the remnant of the gallbladder wall. The recovery course was unremarkable.

Background: Mitral Annular Disjunction (MAD) refers to embryologic fibrous separation between mitral annular ring and basal left ventricular myocardium. Since its original description, the role of MAD in arrhythmic mitral valve prolapse (MVP) has been subject of active research. In this study we sought to assess prognostic and imaging characteristics of MVP patients with and without underlying MAD. Methods: Patients with posterior or bi-leaflet MVP were retrospectively identified via a review of all patients referred to our cardiac magnetic resonance (CMR) imaging laboratory from January 2015 to May 2022. MVP patients were further stratified by underlying MAD status. CMR characteristics including late gadolinium enhancement (LGE) distribution, clinical characteristics, and data on mitral valve intervention were determined. Results: A total of 100 MVP patients undergoing CMR imaging (52 MVP patients with posterior MAD) were retrospectively identified with female comprising 55% of the cohort. MVP patients with MAD were more likely to have an abnormal basal inferolateral/ papillary muscles LGE (51% vs 21%, p<0.01). Posterior MAD longitudinal disjunction gap in ‘mm’ was a predictor of ventricular tachycardia (VT) [1.23, p=0.03)]. Similarly, posterior MAD as a binary variable was predictor of VT (11, p<0.01), ventricular arrhythmia (composite of VT, and non-sustained VT) (2.4, p=0.03), and major adverse cardiac events (MACE) (composite of VT, syncope, and mitral valve intervention) (2.5, p=0.03). Using ROC curve analysis, a disjunction gap of > 4 mm was predictive of VT (AUC-0.71, p<0.01), and incorporation of LGE in ROC model further improved AUC to 0.78 confirmed via Akaike information criterion (p<0.05), see Figure. Conclusion: Abnormal LGE involving basal inferolateral myocardium and papillary muscles may provide substrate for arrythmia in MVP patients. Further, for the first time, a MAD threshold of > 4 mm is demonstrated to stratify the VT risk.

Normal aortic compliance allows cardiac output to be distributed throughout the cardiac cycle, resulting in lower peak blood velocity. Loss of compliance with aging, hypertension, and possibly other risk factors for atherosclerosis increases peak blood velocity, creating eddy currents in areas of changing vascular geometry, as well as creating adverse patterns of diastolic flow. In the resulting areas of low flow, increased blood viscosity creates the potential for thrombosis. Occlusive thrombi may cause death; parietal or mural thrombi may organize to form atherosclerotic plaques.

In this case study report of an infant with metabolic alkalosis, the healthcare team worked to discover the cause of the illness. They found that well-meaning parents had diluted their newborn's powdered formula with electrolyte-enhanced water. Electrolyte balance in the newborn is reviewed in this article, along with information about enhanced waters. It is essential that nurses working with new families be aware that heavily advertised enhanced waters could be used unknowingly by parents for their newborns, and that the consequences could be dire.

Staff Nurse • Orthopedics and Neurology • Benefis Healthcare • Great Falls, Mont. The author has disclosed that she has no significant relationships with or financial interest in any commercial companies that pertain to this educational activity.

The purpose of the Vermont Oxford Neonatal Quality Improvement Collaborative 2005 was to explore improvements related to the physical environment of the newborn intensive care unit (NICU) in order to optimize the neurodevelopmental outcome of newborns. Five centers were involved in a focus group examining NICU environmental design and its impact on the neurodevelopmental outcome of the neonate. Using an evidence-based approach, the group identified 16 potentially better care practices. This article describes the implementation approaches for some of these practices. The practice areas include tactile stimulation, providing early exposure to mother's scent, minimizing exposure to noxious odors, developing a system for noise assessment of the NICU acoustic environment, minimizing ambient noise in the infants environment, and preservation of sleep. Approaches to implementation were center specific. Optimizing neurodevelopment of the newborn was the desired goal, but this outcome is difficult to measure with a limited number of subjects over a short study period. Many of the changes although intuitively beneficial are difficult to measure. Education of all participants was considered essential to the process of implementation. The process of collaborative quality improvement is useful in identifying ways to optimize the physical environment of the NICU to improve the neurodevelopmental outcome of the neonate.

Cycle ergometry is commonly used in pulmonary rehabilitation programs for cardiorespiratory fitness training. Patient position during cycling exercise is generally not standardized, but could affect exercise response. The purpose of this study was to assess physiologic responses in patients with chronic obstructive pulmonary disease (COPD) during upright and forward leaning cycling exercise. Seven females and three males diagnosed with COPD volunteered to participate in this study. Patients performed a submaximal cycling exercise protocol. The patients were positioned with the trunk upright or inclined 45° forward during the submaximal cycling exercise protocol. The patient returned to the laboratory within 2-4 days and repeated the same submaximal exercise protocol as the first testing day, but seated in the other position. The order of cycling position was determined randomly with a card draw for the first subject and alternated thereafter. Physiologic parameters measured included heart rate (HR), minute ventilation (VE), tidal volume (VT), respiratory rate (RR), oxygen consumption (VO2), and the ventilatory equivalent for oxygen (VE/VO2). Rating of perceived exertion (RPE) was also recorded during each minute of the submaximal exercise protocol. Data collected during the last minute of the steady state exercise was averaged and analyzed for between trial differences using a paired t-test. The RPE scores during the final minute of steady state exercise were analyzed using a Wilcoxon Signed RankTest. No significant differences were found between upright and forward inclined submaximal cycling for any of the parameters analyzed.