Pulmonary embolism (PE), a blood clot in the lungs which causes shortness of breath and chest pain, is the third leading cardiovascular cause of death in the United States with more than 100, 000 lives taken each year. A typical intervention for PE patients includes anticoagulants in an effort to prevent migration of the blood clot, but the higher-risk PE population – about 30 percent of all PE patients – are potential candidates for catheter-directed thrombolysis (CDT) and systemic thrombolysis (ST), both of which employ ‘clot-busting’ medications known as tissue plasminogen activator (tPA).

However, in a new study, researchers from the Perelman School of Medicine at the University of Pennsylvania have found that the utilization rates of these potentially life-saving medications are low, particularly in the sub-group of PE patients who are critically ill.

ST is the method in which ‘clot-busting’ medication is administered intravenously (IV) to eliminate clots throughout the bloodstream, while CDT allows the medication to be directly administered into the clot in the lungs.
‘For years, ST and CDT have been available for use in patients with PE, however, there has been little research done to understand how these therapies are being utilized in the real-world,’ said the study’s presenter Srinath Adusumalli, MD, chief cardiovascular medicine fellow in the Perelman School of Medicine at the University of Pennsylvania. ‘Our initial data suggest that, in fact, both ST and CDT are used infrequently to treat PE, including in young, critically ill patients who may experience the highest clinical benefit from those therapies.’
Adusumalli and his colleagues performed a retrospective study in which they collected data from the OptumInsight national commercial insurance claims database and identified 100,744 patients who had been hospitalized with PE during a ten-year period (2004-2014). This is the first study of its kind to examine detailed procedural coding for pulmonary embolism therapies from a national database, allowing researchers to aggregate information from a national population rather than hospital or region-specific information. The team culled through the data and found that of the 100,744 patients hospitalized with PE, 2,175 patients received either CDT or ST – roughly two percent of all PE patients. In this same timeframe, the number of PE hospitalizations increased by 306 percent.

‘Another question that emerged from these findings is whether we are adequately matching the right patients to the right therapies at the right time,’ said senior author Peter W. Groeneveld, MD, MS, an associate professor of Medicine, research director in the Leonard Davis Institute of Health Economics, and director of Penn’s Cardiovascular Outcomes, Quality, and Evaluative Research Center. ‘Since there is a lack of real-world clinical effectiveness and safety data on these therapies and a resulting lack of guideline-based recommendations, substantial clinical uncertainty persists as to when and in whom to use CDT and ST.’

A larger team at Penn Medicine, including those who were involved with this study, created what’s called the Pulmonary Embolism Response Team – or PERT – which is designed to employ rapid response techniques for the treatment of PE in order to match the right patient to the right therapy at the right time.
‘The purpose of PERT is to ensure that high-risk PE patients are receiving the best kind of treatment plan on the most efficient timeline in order to improve outcomes,’ said Jay Giri, MD, MPH, an assistant professor of Cardiovascular Medicine and founder of the PERT at the Hospital of the University of Pennsylvania. ‘However, it is important to state that most decisions made by PERT physicians are a matter of clinical consensus rather than being based on rigorous comparative effectiveness research. The current study re-emphasizes the clinical consequences of the dearth of data in the PE field.’

Perelman School of Medicine www.pennmedicine.org/news/news-releases/2017/march/high-risk-pulmonary-embolism-patients-often-go-without-most-effective-treatments

The Eustachian tube is the main connection between the back of the throat and the middle of the ear. Normally, the tube is filled with air and opens when yawning or chewing. “This allows you to equalize pressure” on either side of the eardrum, explained David Kaylie, MD, a Duke otolaryngologist. When the tube is blocked from a cold or sinus, nose or ear infection, air can no longer pass through. Stuffy ears and noses, hearing loss, ear pain and pressure, as well as ringing in the ears (tinnitus) can result.
Blocked Eustachian tubes can be relieved by nasal sprays and antihistamine tablets, which reduce inflammation and congestion. Recurrent Eustachian tube dysfunction requires the surgical placement of tubes in the eardrum, which allows pressure to equalize in the middle ear. Now that the FDA has approved the Aera system, children, and adults with chronic Eustachian tube dysfunction, can opt for a simple, 10-minute procedure instead, Kaylie said.
“This new device has been shown to return the middle ear to normal and greatly eliminate middle ear pressure in properly selected patients,” he said. Studies of the device showed “long term normal Eustachian function after the procedure.”
David Kaylie, MD, performs the minimally invasive procedure in the OR, but no overnight stay is required.
During the minimally invasive procedure, a catheter is used to insert a small balloon through the nose and into the Eustachian tube. The balloon is inflated, which opens the Eustachian tube and allows air to flow through. Once the tube is open, the balloon is deflated and removed.
While Kaylie believes the device will prove useful to many people who currently require ear tube surgery due to Eustachian tube dysfunction, fluid in their ears, or chronic ear infections, he also cautions that there are some people for whom it will not be appropriate. During the clinical trial for the Aera system, some common problems included small tears in the lining of the Eustachian tube, minor bleeding and, sometimes, worsening or their Eustachian tube dysfunction.
Still, Kaylie believes it will be a significant advance for the millions of people who require ear tube surgery. “There are people who need tubes 13 or 14 times,” he said. “Every time the tubes come out, they need the tubes in again. There is a huge need for this procedure, and it will greatly reduce the need for all those ear tubes” and other related surgeries.

Duke Universityhttp://tinyurl.com/yanrxgb8

In a first-of-its-kind study, Mount Sinai researchers have discovered a novel technique to monitor laryngeal and vagus nerve function while patients are under anaesthesia during otolaryngology and neurosurgery procedures. The findings could save patients from vocal paralysis, maintain their swallowing function, and transform the way doctors perform surgeries.
Laryngeal nerve injuries following thyroid or anterior cervical spine surgeries affect approximately 10 percent of patients. To prevent these injuries, doctors typically monitor these nerves intermittently by stimulating them at various times through the procedure. But with intermittent monitoring, a possible nerve injury can be missed. Continuous stimulation allows doctors to see damage before it occurs and take preventative measures, but until now the only method of continuous monitoring has required doctors to place an electrode around the vagus nerve in the neck (this cranial nerve extends from the brainstem to the abdomen and helps supply voice and swallowing functions and control heart, lungs and digestion), which is invasive for the patient and can cause surgical complications.
Mount Sinai researchers recently developed a new, less invasive technique to continuously oversee the nerve function throughout thyroid procedures and cervical spine fusions. This novel technique relies solely on a special type of breathing or endotracheal tube, inserted by the anaesthesiologist at the start of the surgical procedure. They use the tube to both stimulate and monitor nerve responses during the entire surgery, which has never been done before. This technique allows surgeons to see how different surgical manoeuvres affect nerve function, and then change their approach to prevent post-surgical voice and swallowing complications resulting from nerve dysfunction during the procedure. According to their research results, this technique may improve patient outcomes and lower complication rates.
"This simple technique will likely have wide-reaching effects by greatly enhancing our ability to monitor the vagus nerve in the head and neck during neurosurgical and cardiothoracic surgeries. It requires no equipment other than a monitored breathing tube, and this type of tube is generally already used in most of these surgeries," said lead investigator Catherine Sinclair, MD, FRACS, Assistant Professor, Otolaryngology, Icahn School of Medicine at Mount Sinai. "Never before have we been able to monitor both sensory and motor branches of the vagus nerve. The ability to monitor sensory function for the first time is a huge breakthrough and will hopefully translate into improved patient outcomes."

EurekAlert
www.eurekalert.org/pub_releases/2017-07/tmsh-ms062617.php

A team led by researchers from the Stanford University School of Medicine has demonstrated a way to diagnose cancer without resorting to surgery, raising the possibility of far fewer biopsies.

For this first-in-humans clinical trial, women with either breast or ovarian tumours were injected intravenously with microbubbles capable of binding to and identifying cancer.

Jurgen Willmann, MD, a professor of radiology at Stanford, is lead author, and Sanjiv ‘Sam’ Gambhir, MD, PhD, professor and chair of radiology, is the senior author of the study.

For the study, 24 women with ovarian tumours and 21 women with breast tumours were intravenously injected with the microbubbles. Clinicians used ordinary ultrasound to image the tumours for about a half-hour after injection. The high-tech bubbles clustered in the blood vessels of tumours that were malignant, but not in those that were benign.

The ultrasound imaging of patients’ bubble-labelled tumours was followed up with biopsies and pathology studies that confirmed the accuracy of the diagnostic microbubbles.

Medical microbubbles are spheres of phospholipids, the same material that makes up the membranes of living cells. The bubbles are 1 to 4 microns in diameter, a little smaller than a red blood cell, and filled with a harmless mixture of perfluorobutane and nitrogen gas.

Ordinary microbubbles have been approved by the Food and Drug Administration and in clinical use for several years now. But such microbubbles, a kind of ultrasound ‘contrast agent,’ have only been used to image organs like the liver by displaying the bubbles as they pass through blood vessels. Up to now, the bubbles couldn’t latch onto blood vessels of cancer in patients.

The microbubbles used in this study were designed to bind to a receptor called KDR found on the tumour blood vessels of cancer but not in healthy tissue. Noncancerous cells don’t have such a receptor. Under ultrasound imaging, the labelled microbubbles, called MBKDR, show up clearly when they cluster in a tumour. And since benign breast and ovarian tumours usually lack KDR, the labelled microbubbles mostly passed them by.

In this small, preliminary safety trial, the technique appeared to be both safe and very sensitive, said Willmann, who is chief of the Division of Body Imaging at Stanford. And it also works with ordinary ultrasound equipment. ‘So, there’s no new ultrasound equipment that needs to be built for that,’ he said. ‘You can just use your regular ultrasound and turn on the contrast mode – which all modern ultrasound equipment has.’

Stanford Medicinemed.stanford.edu/news/all-news/2017/04/ultrasound-and-microbubbles-flag-malignant-cancer-in-humans.html

A new study finds that about one in three patients admitted to the hospital exhibits symptoms of depression, potentially affecting their clinical outcomes. Depressive symptoms can delay recovery time, increase length of hospital stays, and increase the frequency of readmissions, for example.

The findings suggest that screening hospitalized patients for depression should be as routine as testing for physical markers, such as blood pressure and cholesterol.

For the study, researchers from the Department of Psychiatry and the Department of Medicine at Cedars-Sinai Medical Center in Los Angeles analysed data from 20 studies on depression screenings in hospitals. They discovered that 33 percent of hospitalized patients had symptoms of depression such as feeling down or hopeless, having little interest or pleasure in doing things, and experiencing significant sleep and appetite changes.

Lead author Waguih William IsHak, M.D., said that patients who have symptoms of depression are less likely to take their medications and keep up with their outpatient appointments. These behaviours could lead to delayed recoveries, longer hospital stays, and a greater chance of hospital readmissions.

‘Upon admission to the hospital, patients are screened for all kinds of medical issues such as abnormalities in blood pressure, cholesterol and blood sugar,’ IsHak said. ‘Adding a screening for depression seizes a golden opportunity to initiate and maintain treatment.’

Cedars-Sinai routinely screens all hospitalized adult patients for depression. The screenings, performed by nurses within 24 hours of patient admission, comprise two questions on mood and interest in pleasurable activities.

If indications of depressive symptoms arise, nurses then give the patient a more detailed questionnaire about energy, concentration, appetite, sleep patterns, and other indications of depression.

Patients who screen positive for depressive symptoms receive interventions from their Cedars-Sinai admitting physicians, social workers and the psychiatry team, which includes psychiatrists, psychologists, psychiatric social workers, and a psychiatric nurse.

‘We know that depression is a serious factor in any patient’s recovery,’ IsHak said. ‘These findings show that hospitals might experience improved outcomes by initiating a depression screening program.’

News Locker www.newslocker.com/en-uk/news/psychology/study-1-in-3-hospital-patients-shows-signs-of-depression/view/