Mercy Medical Center North Iowa

AimsCardiac resynchronization therapy (CRT) reduces morbidity and mortality for patients with heart failure, reduced left ventricular ejection fraction, QRS duration >130 ms and in sinus rhythm. The aim of this study was to identify patient characteristics that predict the effect, specifically, of CRT pacemakers (CRT‐P) on all‐cause mortality or the composite of hospitalization for heart failure or all‐cause mortality.Methods and resultsWe conducted an individual patient data meta‐analysis of the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) and Cardiac Resynchronization‐Heart Failure (CARE‐HF) trials. Only patients assigned to CRT‐P or control (n = 1738) were included in order to avoid confounding from concomitant defibrillator therapy. The influence of baseline characteristics on treatment effects was investigated. Median age was 67 (59–73) years, most patients were men (70%), 68% had a QRS duration of 150–199 ms and 80% had left bundle branch block. Patients assigned to CRT‐P had lower rates for all‐cause mortality (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.56–0.81; p < 0.0001) and the composite outcome (HR 0.67, 95% CI 0.58–0.78; p < 0.0001). No pre‐specified characteristic, including sex, aetiology of ventricular dysfunction, QRS duration (within the studied range) or morphology or PR interval significantly influenced the effect of CRT‐P on all‐cause mortality or the composite outcome. However, CRT‐P had a greater effect on the composite outcome for patients with lower body surface area and those prescribed beta‐blockers.ConclusionsCardiac resynchronization therapy‐pacemaker reduces morbidity and mortality in appropriately selected patients with heart failure. Benefits may be greater in smaller patients and in those receiving beta‐blockers. Neither QRS duration nor morphology independently predicted the benefit of CRT‐P.Clinical Trial Registration: COMPANION, NCT00180258; CARE‐HF, NCT00170300.

Pneumothorax and pneumomediastinum are known complications of COVID-19 patients. They have been documented to occur both with and without mechanical ventilation. There are several reports of cases further complicated by alveolopleural or bronchopleural fistulas. However, there are no studies and only a few case reports on the treatment options used for alveolopleural fistulas in COVID-19 patients. To our knowledge, there is only one report of bronchoscopic treatment with endobronchial valves in a COVID-19 patient. We present the case of a 63-year-old male with COVID-19, pneumothorax, and an alveolopleural fistula that was successfully sealed using bronchoscopic occlusion with a Swan-Ganz catheter.

We hypothesized that survival in implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy defibrillator (CRT-D) patients is predicted by baseline Heart Rate Score. Heart Rate Score is determined from the atrial paced and sensed histogram of a DDD ICD or CRT-D, and defined as percent of beats in the histogram in the tallest 10 beats/min range bin. It was calculated at initial remote monitoring for patients enrolled in LATITUDE® without persistent atrial fibrillation, and with pulse generators implanted in 2006-2011. Univariate, multivariate, and Kaplan-Meier analyses determined the impact of Heart Rate Score on survival. Of 57,893 ICDs and 67,929 CRT-Ds followed for 2.4 ± 1.5 years, each 10% increase in Heart Rate Score was associated with decreased survival (CRT-D hazard ratio [HR] 1.07 95%, confidence interval 1.06-1.07, P < 0.0001; ICD HR 1.05, 95% confidence interval 1.04-1.06, P < 0.0001). Multivariate analysis showed survival decreased with increasing age, atrial fibrillation, presence of a shock in first-year follow-up, and increasing programmed lower pacing rate in ICD and CRT-D patients. Increased percent right ventricular pacing predicted mortality in ICD patients, while male gender and lower percent left ventricular pacing predicted mortality in CRT patients. Heart Rate Score predicted survival independent of those variables. Heart Rate Score correlates with heart rate variability (standard deviation of average R-R intervals [SDANN]) when both are obtainable, but SDANN was only present in 6% of patients with Heart Rate Score >70%. A simple device histogram measure, Heart Rate Score, predicts survival in ICD and CRT-D patients independent of the available variables, and even when SDANN is unavailable.

Cardiac thrombi often present as a homogenous echodensity on cardiac imaging that may be incidentally discovered. A thrombus must be differentiated from vegetations, tumors and normal variant anatomy as their treatments are different. Cardiac thrombi are often located in cardiac chambers, most commonly the left atrium and left atrial appendage, where there is more stagnant blood flow. Thrombi may also form in structurally altered cardiac chambers as well as seen in dilated cardiomyopathy and in ventricular aneurysms. Symptoms, if present, may vary from dyspnea, angina and compressive symptoms. Currently, transthoracic echocardiography, transesophageal echocardiography and magnetic resonance imaging (MRI) are the accepted modalities to evaluate cardiac masses. MRI has been used with more frequency due to its ability to delineate mass borders, determine endocardial involvement and in its ability to detect blood flow. Few cases have been described of a large cardiac thrombus extending through the valves to include multiple chambers. In our case presentation, we describe a 91-year-old female with no significant cardiac history who presented with a non-ST elevation myocardial infarction where a transthoracic echocardiogram revealed a large intracavitary thrombus. J Med Cases. 2016;7(7):303-306 doi: http://dx.doi.org/10.14740/jmc2553w

The purpose of this study was to describe the extent of change in patient care orders primarily for six diagnoses, procedures, or conditions in a not-for-profit Midwestern rural referral hospital. A descriptive method was used to analyze changes in the order sets over time for chest pain with acute myocardial infarction, degenerative osteoarthritis with hip joint replacement and degenerative osteoarthritis with knee joint replacement procedures, coronary artery bypass graft procedures, congestive heart failure, and pneumonia. Ten items about service-specific order sets were abstracted during pre- and post-EHR implementation and a year later. We then examined use 5 years later. The findings illustrate how the order sets evolved with multiple nested order sets to facilitate computerized provider order entry with a rate greater than 70% by physicians. The total number of available patient care orders within the order sets increased primarily because of linked nested order sets related to medications and diagnostic tests. Five years later, 50% of the orders were medication orders. In conclusion, this was important to deploy the order sets within smaller critical-access hospital facilities to train providers in adopting order sets internally.

Across the healthcare system, staff development specialists and nurse leaders have been challenged with the development, implementation, and evaluation of processes by which clinical nursing staff demonstrate competence in an efficient and effective manner. The purpose of this article is to describe one approach used in an acute care setting. Staff development specialists and nurse leaders played key roles in assessing, developing, and evaluating a nursing competency validation fair.