RESUMEN

Experience with intravascular lithotripsy (IVL) following stent deployment in saphenous vein graft (SVG) lesions is limited. We present 2 cases of percutaneous intervention in SVG in which acute stent underexpansion was successfully managed with IVL. In the first case, recalcitrant plaque required prestent deployment IVL, with intracoronary imaging showing persistent calcification. Additional poststent deployment IVL facilitated full expansion and successful stent delivery. In the second case, predilation with semicompliant balloons appeared angiographically effective, but stent deployment showed acute underexpansion. Postdilation with noncompliant balloons and ultimately IVL allowed full expansion and successful stent delivery. These are the first reported cases of IVL use immediately after stent deployment in SVG to treat underexpansion due to recalcitrant calcification.

RESUMEN

PURPOSE OF REVIEW: Because of effective combination antiretroviral therapy, people living with HIV (PLWH) are living longer but developing chronic age-related conditions including cardiovascular disease (CVD), the leading cause of death globally. This review aims to discuss the epidemiology, mechanisms, and clinical considerations of CVD in PLWH from a global perspective. RECENT FINDINGS: PLWH are at greater risk for CVD at chronologically younger ages than those without HIV. Potential underlying mechanisms for CVD in PLWH include systemic inflammation, comorbidities, immune-mediated, or treatment-related mechanisms. There is also risk factor variation based on geographical location, including non-traditional CVD risk factors. CVD is prevalent in PLWH and increasing on a global scale. Further understanding the unique epidemiology, risk factors, and treatment of CVD in this population will improve the care of PLWH.

Asunto(s)

RESUMEN

PURPOSE OF REVIEW: The past few decades have seen significant technologic innovation for the treatment and diagnosis of cardiovascular diseases. The subsequent growing complexity of modern medicine, however, is causing fundamental challenges in our healthcare system primarily in the spheres of patient involvement, data generation, and timely clinical implementation. The Institute of Medicine advocated for a learning health system (LHS) in which knowledge generation and patient care are inherently symbiotic. The purpose of this paper is to review how the advances in technology and big data have been used to further patient care and data generation and what future steps will need to occur to develop a LHS in cardiovascular disease. RECENT FINDINGS: Patient-centered care has progressed from technologic advances yielding resources like decision aids. LHS can also incorporate patient preferences by increasing and standardizing patient-reported information collection. Additionally, data generation can be optimized using big data analytics by developing large interoperable datasets from multiple sources to allow for real-time data feedback. Developing a LHS will require innovative technologic solutions with a patient-centered lens to facilitate symbiosis in data generation and clinical practice.

Asunto(s)

RESUMEN

PURPOSE: There is concern that graduating surgery residents are not prepared for independent practice. This study aimed to identify predictors of performance, autonomy, and readiness for independence ratings of trainees by attendings for thyroidectomy and parathyroidectomy with respect to repeated resident-attending exposure. We hypothesized that increased exposure with a particular attending increases resident autonomy. METHODS: All residents and faculty at a single institution performing parathyroidectomy or thyroidectomy were invited to complete an operative performance evaluation at case competition using the Zwisch scale to measure performance and autonomy for individual operative steps. In addition, each survey evaluated the trainee's readiness for practice in a straightforward procedure as a binary variable. Categorical variables were evaluated via Chi-squared or Fisher's exact tests and ordinal variables were evaluated with Wilcoxon or Kruskal-Wallis tests. Multivariable analysis was conducted with random effects logistic regression, and learning curves were generated for each procedure. RESULTS: Operative performance evaluations were obtained from 36 individual learners and 6 faculty members, with a total of 145 evaluations for parathyroidectomy and 116 for thyroidectomy. On bivariate analysis, readiness for practice ratings was significantly associated with increasing chronologic procedure number, but not resident gender or case difficulty. The multivariable model demonstrated that increasing chronologic procedure number, while a significant predictor without accounting for exposure, did not remain a significant predictor of practice-readiness for parathyroidectomy when accounting for resident-attending exposure. Bivariate analysis comparing resident and attending ratings showed no difference between the 2, but there were significant differences in autonomy and performance scores for both groups of raters. Trainees rated by attendings as independence ready completed a median of 7 parathyroidectomies and 5 thyroidectomies. Descriptive learning curves generated serve as a model of the multistate nature that residents undergo when moving from novice to proficiency. CONCLUSIONS: Not surprisingly, the more operations residents perform with a single attending, the higher their ratings for performance and autonomy from that individual, with increased exposure allowing improved performance with less attending autonomy. By contrast, our data also show that repeated exposure between resident and attending may confound the use of procedural numbers alone when predicting resident ability in the operating room.

Asunto(s)

RESUMEN

In spite of intense interest in how altered epigenetic processes including DNA methylation may contribute to psychiatric and neurodevelopmental disorders, there is a limited understanding of how methylation processes change during early postnatal brain development. The present study used in situ hybridization to assess mRNA expression for the three major DNA methyltranserases (DNMTs)--DNMT1, DNMT3a and DNMT3b--in the developing rat brain at seven developmental timepoints: postnatal days (P) 1, 4, 7, 10, 14, 21, and 75. We also assessed 5-methylcytosine levels (an indicator of global DNA methylation) in selected brain regions during the first three postnatal weeks. DNMT1, DNMT3a and DNMT3b mRNAs are widely expressed throughout the adult and postnatal developing rat brain. Overall, DNMT mRNA levels reached their highest point in the first week of life and gradually decreased over the first three postnatal weeks within the hippocampus, amygdala, striatum, cingulate and lateral septum. Global DNA methylation levels did not follow this developmental pattern; methylation levels gradually increased over the first three postnatal weeks in the hippocampus, and remained stable in the developing amygdala and prefrontal cortex. Our results contribute to a growing understanding of how DNA methylation markers unfold in the developing brain, and highlight how these developmental processes may differ within distinct brain regions.

Asunto(s)