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Conclusion: Both tinnitus masking (TM) and tinnitus retraining therapy (TRT) can be effective therapies for amelioration of tinnitus. TM may be more effective for patients in the short term, but with continued treatment TRT may produce the greatest effects. Objectives: Although TM and TRT have been used for many years, research has not documented definitively the efficacy of these methods. The present study was a controlled clinical trial to prospectively evaluate the clinical efficacy of these two methods for US military veterans with severe tinnitus. Subjects and methods: Over 800 veterans were screened to ensure that enrolled patients had tinnitus of sufficient severity to justify 18 months of individualized treatment. Qualifying patients (n=123) were placed quasi-randomly (alternating placement) into treatment with either TM or TRT. Treatment was administered at 0, 3, 6, 12, and 18 months. Outcomes of treatment were evaluated primarily using three self-administered tinnitus questionnaires (Tinnitus Handicap Inventory, Tinnitus Handicap Questionnaire, Tinnitus Severity Index). Results: Findings are presented from the three written questionnaires with respect to three categories of patients: describing tinnitus as a 'moderate,' 'big,' and 'very big' problem at baseline. Based on effect sizes, both groups showed considerable improvement overall. In general, TM effects remained fairly constant over time while TRT effects improved incrementally. For the patients with a 'moderate' and 'big' problem, TM provided the greatest benefit at 3 and 6 months; benefit to these TRT patients was slightly greater at 12 months, and much greater at 18 months. For patients with a 'very big' problem, TM provided the greatest benefit at 3 months. For these latter patients, results were about the same between groups at 6 months, and improvement for TRT was much greater at 12 months, with further gains at 18 months. [ABSTRACT FROM AUTHOR]

Audiology clinics are increasingly being asked to provide tinnitus treatment services to patients who are severely distressed by tinnitus. It is unclear what levels of tinnitus care are available at different audiology clinics across the nation. Some clinics have staff who are experienced with the tinnitus masking technique or with tinnitus retraining therapy (TRT), whereas other clinics may limit their care to the provision of hearing aids. This article is an attempt to provide some basic information for those clinicians who would like to provide at least a minimum level of care for their tinnitus patients using the tinnitus masking approach. The most important requirement is a commitment by the clinician to assemble some basic resources and to structure the clinical schedule so that adequate time is available for historical review, evaluation, trial and selection of devices, and tinnitus counseling. A minimum set of measurements is recommended for inclusion in the tinnitus evaluation process. This informal review summarizes a variety of clinical observations culled from years of direct patient care experience. A tinnitus questionnaire is provided to help clinicians review potentially relevant issues. [ABSTRACT FROM AUTHOR]

Two methods for treating tinnitus are compared. Tinnitus masking has been used for over 25 years, and although this method is used in clinics around the world, there are many misconceptions regarding the proper protocol for its clinical application. Tinnitus retraining therapy has been used clinically for over 12 years and has received considerable international attention. Although these methods are distinctive in their basic approach to tinnitus management, certain aspects of treatment appear similar. These aspects of treatment have created considerableconfusion and controversy, especially regarding the use of 'sound therapy' as a basic component of treatment. It is the objective of this article to clarify the major differences that exist between these two forms of treatment. [ABSTRACT FROM AUTHOR]

Abstract Background Factors associated with HCV incidence among young Aboriginal people in Canada are still not well understood. We sought to estimate time to HCV infection and the relative hazard of risk factors associated HCV infection among young Aboriginal people who use injection drugs in two Canadian cities. Methods The Cedar Project is a prospective cohort study involving young Aboriginal people in Vancouver and Prince George, British Columbia, who use illicit drugs. Participants’ venous blood samples were drawn and tested for HCV antibodies. Analysis was restricted to participants who use used injection drugs at enrolment or any of follow up visit. Cox proportional hazards regression was used to identify independent predictors of time to HCV seroconversion. Results In total, 45 out of 148 participants seroconverted over the study period. Incidence of HCV infection was 26.3 per 100 person-years (95% Confidence Interval [CI]: 16.3, 46.1) among participants who reported using injection drugs for two years or less, 14.4 per 100 person-years (95% CI: 7.7, 28.9) among participants who had been using injection drugs for between two and five years, and 5.1 per 100 person-years (95% CI: 2.6,10.9) among participants who had been using injection drugs for over five years. Independent associations with HCV seroconversion were involvement in sex work in the last six months (Adjusted Hazard Ratio (AHR): 1.59; 95% CI: 1.05, 2.42) compared to no involvement, having been using injection drugs for less than two years (AHR: 4.14; 95% CI: 1.91, 8.94) and for between two and five years (AHR: 2.12; 95%CI: 0.94, 4.77) compared to over five years, daily cocaine injection in the last six months (AHR: 2.47; 95% CI: 1.51, 4.05) compared to less than daily, and sharing intravenous needles in the last six months (AHR: 2.56; 95% CI: 1.47, 4.49) compared to not sharing. Conclusions This study contributes to the limited body of research addressing HCV infection among Aboriginal people in Canada. The HCV incidence rate among Cedar Project participants who were new initiates of injection drug use underscores an urgent need for HCV and injection prevention and safety strategies aimed at supporting young people surviving injection drug use and sex work in both cities. Young people must be afforded the opportunity to provide leadership and input in the development of prevention programming.

Abstract Background Changes in CD4 cell counts are poorly documented in individuals with low or moderate-level viremia while on antiretroviral treatment (ART) in resource-limited settings. We assessed the impact of on-going HIV-RNA replication on CD4 cell count slopes in patients treated with a first-line combination ART. Method Naïve patients on a first-line ART regimen with at least two measures of HIV-RNA available after ART initiation were included in the study. The relationships between mean CD4 cell count change and HIV-RNA at 6 and 12 months after ART initiation (M6 and M12) were assessed by linear mixed models adjusted for gender, age, clinical stage and year of starting ART. Results 3,338 patients were included (14 cohorts, 64% female) and the group had the following characteristics: a median follow-up time of 1.6 years, a median age of 34 years, and a median CD4 cell count at ART initiation of 107 cells/μL. All patients with suppressed HIV-RNA at M12 had a continuous increase in CD4 cell count up to 18 months after treatment initiation. By contrast, any degree of HIV-RNA replication both at M6 and M12 was associated with a flat or a decreasing CD4 cell count slope. Multivariable analysis using HIV-RNA thresholds of 10,000 and 5,000 copies confirmed the significant effect of HIV-RNA on CD4 cell counts both at M6 and M12. Conclusion In routinely monitored patients on an NNRTI-based first-line ART, on-going low-level HIV-RNA replication was associated with a poor immune outcome in patients who had detectable levels of the virus after one year of ART.

Abstract Background Substitution with opioid-agonists (e.g., methadone) has shown to be an effective treatment for chronic long-term opioid dependency. Survival sex work, very common among injection drug users, has been associated with poor Opioid Agonist Treatment (OAT) engagement, retention and response. Therefore, this study was undertaken to determine factors associated with engaging in sex work among long-term opioid dependent women receiving OAT. Methods Data from a randomized controlled trial, the North American Opiate Medication Initiative (NAOMI), conducted in Vancouver and Montreal (Canada) between 2005-2008, was analyzed. The NAOMI study compared the effectiveness of oral methadone to injectable diacetylmorphine or injectable hydromorphone, the last two on a double blind basis, over 12 months. A research team, independent of the clinic services, obtained outcome evaluations at baseline and follow-up (3, 6, 9, 12, 18 and 24 months). Results A total 53.6% of women reported engaging in sex work in at least one of the research visits. At treatment initiation, women who were younger and had fewer years of education were more likely to be engaged in sex work. The multivariate logistic generalized estimating equation regression analysis determined that psychological symptoms, and high illicit heroin and cocaine use correlated with women's involvement in sex work during the study period. Conclusions After entering OAT, women using injection drugs and engaging in sex work represent a particularly vulnerable group showing poorer psychological health and a higher use of heroin and cocaine compared to women not engaging in sex work. These factors must be taken into consideration in the planning and provision of OAT in order to improve treatment outcomes. Trial Registration NCT00175357.

Abstract Background Substitution with opioid-agonists (e.g., methadone) has shown to be an effective treatment for chronic long-term opioid dependency. Patient satisfaction with treatment has been associated with improved addiction treatment outcomes. However, there is a paucity of studies evaluating patients' satisfaction with Opioid Substitution Treatment (OST). In the present study, participants' satisfaction with OST was evaluated at 3 and 12 months. We sought to test the relationship between satisfaction and patients' characteristics, the treatment modality received and treatment outcomes. Methods Data from a randomized controlled trial, the North American Opiate Medication Initiative (NAOMI), conducted in Vancouver and Montreal (Canada) between 2005-2008, was analyzed. The NAOMI study compared the effectiveness of oral methadone vs. injectable diacetylmorphine over 12 months. A small sub-group of patients received injectable hydromorphone on a double blind basis with diacetylmorphine. The Client Satisfaction Questionnaire (CSQ-8) was used to measure satisfaction with treatment. CSQ-8 scores, as well as retention and response to treatment, did not differ between those receiving hydromorphone and diacetylmorphine at 3 or 12 months assessments; therefore, these two groups were analyzed together as the 'injectable' treatment group. Results A total of 232 (92%) and 237 (94%) participants completed the CSQ-8 at 3 and 12 months, respectively. Participants in both groups were highly satisfied with treatment. Independent of treatment group, participants satisfied with treatment at 3 months were more likely to be retained at 12 months. Multivariate analysis indicated that satisfaction was greater among those randomized to the injection group after controlling for treatment effectiveness. Participants who were retained, responded to treatment, and had fewer psychological symptoms were more satisfied with treatment. Finally, open-ended comments were made by 149 (60.3%) participants; concerns about the randomization process and the study ending were most commonly reported by participants receiving the oral and injectable medications, respectively. Conclusions The higher satisfaction among those receiving medically prescribed injectable diacetylmorphine (or hydromorphone) supports current evidence regarding the attractiveness of this treatment for long-term, opioid-dependent individuals not benefiting sufficiently from other treatments. In addition, the measurement of treatment satisfaction provides valuable information about participants at risk of relapse and in need of additional services. Trial Registration ClinicalTrials.gov Identifier: NCT00175357

Abstract Background Opioid addiction is a chronic, relapsing disease and remains a major public health challenge. Despite important expansions of access to conventional treatments, there are still significant proportions of affected individuals who remain outside the reach of the current treatment system and who contribute disproportionately to health care and criminal justice costs as well as to public disorder associated with drug addiction. The NAOMI study is a Phase III randomized clinical trial comparing injectable heroin maintenance to oral methadone. The study has ethics board approval at its Montréal and Vancouver sites, as well as from the University of Toronto, the New York Academy of Medicine and Johns Hopkins University. The main objective of the NAOMI Study is to determine whether the closely supervised provision of injectable, pharmaceutical-grade opioid agonist is more effective than methadone alone in recruiting, retaining, and benefiting chronic, opioid-dependent, injection drug users who are resistant to current standard treatment options. Methods The case study submitted chronicles the challenges of getting a heroin assisted treatment trial up and running in North America. It describes: a brief background on opioid addiction; current standard therapies for opioid addiction; why there is/was a need for a heroin assisted treatment trial; a description of heroin assisted treatment; the beginnings of creating the NAOMI study in North America; what is the NAOMI study; the science and politics of the NAOMI study; getting NAOMI started in Canada; various requirements and restrictions in getting the study up and running; recruitment into the study; working with the media; a status report on the study; and a brief conclusion from the authors' perspectives. Results and conclusion As this is a case study, there are no specific results or main findings listed. The case study focuses on: the background of the study; what it took to get the study started in Canada; the unique requirements and conditions of getting a site, and the study, approved; working with the media; recruitment into the study; a brief status report on the study; and a brief conclusion from the authors' perspectives. Trail Registration ClinicalTrials.gov registration number: NCT00175357

Abstract Objectives Recent reports have suggested that Aboriginal and American Indian people are at elevated risk of HIV infection. We undertook the present study to compare socio-demographic and risk variables between Aboriginal and non-Aboriginal young (aged 13 – 24 years) injection drug users (IDUs) and characterize the burden of HIV infection among young Aboriginal IDUs. Methods We compared socio-demographic and risk variables between Aboriginal and non-Aboriginal young IDUs. Data were collected through the Vancouver Injection Drug Users Study (VIDUS). Semi-annually, participants have completed an interviewer-administered questionnaire and have undergone serologic testing for HIV and Hepatitis C (HCV). Results To date over 1500 Vancouver IDU have been enrolled and followed, among whom 291 were aged 24 years and younger. Of the 291 young injectors, 80 (27%) were Aboriginal. In comparison to non-Aboriginal youth, Aboriginal youth were more likely to test seropositive for either HIV (20% vs 7%, p=< 0.001) or Hepatitis C virus (HCV) (66% vs 38%, p =< 0.001), be involved in sex work and live in the city's IDU epi-centre at baseline. After 48 months of follow-up, Aboriginal youth experienced significantly higher HIV seroconversion rates than non-Aboriginal youth, 27.8 per ppy (95% CI: 13.4–42.2) vs. 7.0 per ppy (95% CI: 2.3–11.8) respectively (log-rank p = 0.005) and the incidence density over the entire follow-up period was 12.6 per 100 pyrs (CI: 6.49–21.96) and 3.9 per 100 pyrs (CI: 1.8–7.3) respectively. Interpretation These findings demonstrate that culturally relevant, evidence based prevention programs are urgently required to prevent HIV infection among Aboriginal youth.

We study the existence of periodic solutions for second-order nonautonomous dynamical systems. We give four sets of hypotheses which guarantee the existence of solutions. We were able to weaken the hypotheses considerably from those used previously for such systems. We employ a new saddle point theorem using linking methods.

Abstract Background In British Columbia, Canada, all necessary medical services are funded publicly. Concerned with growing wait lists in the mid-1990s, the provincial government started providing extra funding for coronary artery bypass grafting (CABG) operations annually. Although aimed at improving access, it is not known whether supplementary funding changed the time that patients spent on wait lists for CABG. We sought to determine whether the period of registration on wait lists had an effect on time to isolated CABG and whether the period effect was similar across priority groups. Methods Using records from a population-based registry, we studied the wait-list time before and after supplementary funding became available. We compared the number of weeks from registration to surgery for equal proportions of patients in synthetic cohorts defined by five registration periods in the 1990s. Results Overall, 9,231 patients spent a total of 137,126 person-weeks on the wait lists. The time to surgery increased by the middle of the decade, and decreased toward the end of the decade. Relative to the 1991–92 registration period, the conditional weekly probabilities of undergoing surgery were 30% lower among patients registered on the wait lists in 1995–96, hazard ratio (HR) = 0.70 (0.65–0.76), and 23% lower in 1997–98 patients, HR = 0.77 (0.71–0.83), while there were no differences with 1999–2000 patients, HR = 0.94 (0.88–1.02), after adjusting for priority group at registration, comorbidity, age and sex. We found that the effect of registration period was different across priority groups. Conclusion Our results provide evidence that time to CABG shortened after supplementary funding was provided on an annual basis to tertiary care hospitals within a single publicly funded health system. One plausible explanation is that these hospitals had capacity to increase the number of operations. At the same time, the effect was not uniform across priority groups indicating that changes in clinical practice should be considered when adding extra funding to reduce wait lists.

We solve boundary value problems for elliptic semilinear equations in which no asymptotic behavior is prescribed for the nonlinear term.

Clinical management for patients complaining of severe tinnitus has improved dramatically in the last 25 years. During that period of time, various methods of treatment have been introduced and are being used with varying degrees of success. One method that has received considerable attention is tinnitus retraining therapy (TRT). This method is being practiced by hundreds of clinicians worldwide, and retrospective clinical data indicate that TRT has been effective for the majority of patients. This article provides a guide for clinicians to evaluate their patients for treatment with TRT. Included in this guide is the expanded version of the TRT initial interview and specific instructions for the clinician administering the interview. [ABSTRACT FROM AUTHOR]

Background: Studies comparing percutaneous closure of patent ductus arteriosus (PDA) with surgical ligation tend to exclude premature infants and have not assessed procedural charges. We compared our contemporary outcomes and charges of device closure to surgical ligation of PDA in preterm infants., Material and Methods: Preterm infants who underwent isolated PDA closure during their newborn hospitalization (January 2014 to September 2017) were grouped based on intention to treat (surgery versus device closure). Patient demographics, procedural details, and immediate postprocedural outcomes were compared. Procedural charges for device closure versus surgical ligation were compared., Results: Compared with the device group (n = 33), patients undergoing surgical ligation (n = 39) were younger, smaller, and required more preoperative support (P < 0.05). The procedure time was shorter for surgical ligation (P < 0.01). Although there was no procedural mortality in either group, the complication rate was higher for device closure than for surgical ligation (15.2% versus 0%; P = 0.02). The proportion of patients returning to preprocedural respiratory support by 48 h after procedure was similar. There was a higher proportion of surgical patients who required increased inotropic support in the first 24 h after procedure (P = 0.19). The procedural charges for transcatheter device closure were twice as expensive as those for surgical ligation., Conclusions: In our early experience with percutaneous PDA closure, we found a percutaneous approach in preterm infants feasible and well tolerated. Both surgical ligation and device closure were associated with perioperative or postoperative complications. Procedural charges were higher for percutaneous closure, driven by device charge and catheterization room utilization. Further investigation is needed to establish guidelines for first-line therapy for PDA closure in preterm infants, including cost-benefit analysis., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The mortality of ruptured abdominal aortic aneurysms (rAAAs) has been reported as high as 90%. Loss of consciousness and a systolic blood pressure of <80 mm Hg on presentation are the most important predictors of mortality after emergent open repair (OR). Endovascular repair of abdominal aortic aneurysm (EVAR) has reduced short-term operative mortality and morbidity for elective abdominal aortic aneurysm repair, and may be advocated for wider application of EVAR for rAAA. The objective of this study is to compare our experience with OR and EVAR management of rAAA., Methods: Retrospective review of all rAAAs presenting to a tertiary care center between January 1, 2000 and December 31, 2011 was performed. Patients were grouped based on the surgical approach (OR versus EVAR). Patient demographics, intraoperative details, and postoperative mortality and morbidity rates were compared. Statistical analyses were conducted with Stata, version 12., Results: One hundred twenty-six patients presented with rAAA over the study period. Patients who declined repair (n = 14) or died before repair (n = 13) were excluded from this study. Of the 99 patients who underwent repair, 25 patients (25.3%) received EVAR and 74 (74.7%) underwent OR. One patient required conversion to OR from EVAR (1.0%). Overall, 30-day and 1-year mortality was 35.4% and 41.4%, respectively, with no difference seen between the 2 types of repair (30-day mortality: EVAR = 24.0%, OR = 39.2%, P = 0.17; 1-year mortality: EVAR = 32.0%, OR = 44.6%, P = 0.27). Major morbidity also did not differ between the 2 repair procedures (EVAR = 60.0%, OR = 60.8%, P = 0.94). However, patients undergoing EVAR had significantly less estimated blood loss (median: 0.3 vs. 3.0 L, P < 0.0001) and transfusion requirement (median: 5.0 vs. 9.0 U, P = 0.0041). Furthermore, although there was no significant difference in length of overall hospital stay between the 2 groups (8.5 vs. 15 days in the OR group, P = 0.18), significantly more patients in the EVAR group were discharged to home (66.7% vs. 57.1% in the OR group, P = 0.03)., Conclusions: In contrast to recently published series, this series shows no differences in morbidity or mortality between EVAR or OR of rAAAs. EVAR is appropriate in stable patients with a rAAA and favorable anatomy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Extracorporeal membrane oxygenation (ECMO) is being increasingly used as a bridge to lung transplantation. Small, single-institution series have described increased success using ECMO in spontaneously breathing patients compared with patients on ECMO with mechanical ventilation, but this strategy has not been evaluated on a large scale., Methods: Using the United Network for Organ Sharing database, all adult patients undergoing isolated lung transplantation from May 2005 through September 2013 were identified. Patients were categorized by their type of pretransplant support: no support, ECMO only, invasive mechanical ventilation (iMV) only, and ECMO + iMV. Kaplan-Meier survival analysis with log-rank testing was performed to compare survival based on type of preoperative support. A Cox regression model was used to determine whether type of preoperative support was independently associated with survival, using previously established predictors of survival as covariates., Results: Approximately 12,403 primary adult pulmonary transplantations were included in this analysis. Sixty-five patients (0.52%) were on ECMO only, 612 (4.93%) required only iMV, 119 (0.96%) were on ECMO + iMV, and the remaining 11,607 (94.6%) required no invasive support before transplantation. One-year survival was decreased in all patients requiring support, regardless of type. However, mid-term survival was similar between patients on ECMO alone and those not on support but significantly worse with patients requiring iMV only or ECMO + iMV. In multivariable analysis, ECMO + iMV and iMV alone were independently associated with decreased survival compared with nonsupport patients, whereas ECMO alone was not significant., Conclusions: In patients with worsening pulmonary disease awaiting lung transplantation, those supported via ECMO with spontaneous breathing demonstrated improved survival compared with other bridging strategies.

Advances in technology for the delivery of venoarterial extracorporeal membrane oxygenation (VA-ECMO) have allowed for its expanded utilization in the treatment of patients with advanced cardiogenic shock, particularly through the use of peripheral cannulation strategies. However, peripheral VA-ECMO continues to be hampered by several major limitations including inadequate decompression of the left ventricle, lower limb ischemia, and the inability to mobilize patients. Here, we present a case series of three patients who were treated with a hybrid peripheral-central cannulation strategy accompanied by direct decompression of the left ventricle through a right anterior mini-thoracotomy. This novel approach ameliorates several of the current limitations to peripheral VA-ECMO therapy and thereby holds potential for improving outcomes in VA-ECMO patients.

Purpose: In addition to the pulmonary risks associated with cardiopulmonary bypass, thoracic aortic surgery using deep hypothermic circulatory arrest (DHCA) may subject the lungs to further injury. However, this topic has received little investigation to date., Materials and Methods: A prospective cohort review was performed on all patients undergoing proximal thoracic aortic surgery with (n = 478) and without (n = 135) DHCA between July 2005 and February 2013 at a single institution. The primary outcome was prolonged postoperative respiratory support (PPRS), defined as any of the following: >1 day of mechanical ventilation at either fraction of inspired oxygen >0.4 and/or positive end-expiratory pressure >5 mm Hg, >2 days of supplemental O2 requirement of at least 2.5 L/min, or discharge with new O2 requirement. Independent risk factors for PPRS were identified using multivariable logistic regression., Results: Postoperative respiratory support was required in 100 patients (20.9%) with and 30 patients (22.2%) without DHCA (P = .74). Independent predictors of PPRS after proximal aortic surgery included the following: age, diabetes, history of stroke, preoperative creatinine, American Society of Anesthesiologists class 4, redo-sternotomy, total arch replacement, and transfusion requirement. Use of DHCA was not an independent risk factor for PPRS in the entire cohort. Subanalysis of only DHCA patients revealed that longer DHCA times were independently associated with PPRS., Conclusions: Prolonged postoperative respiratory support is common after proximal aortic surgery. The use of DHCA was not associated with this complication in the overall cohort, although longer DHCA times were predictive when only the subset of patients undergoing DHCA was analyzed. Knowledge of the risk factors for PPRS after proximal aortic surgery should improve preoperative risk stratification and postoperative management of these patients., Competing Interests: ☆☆ Financial/nonfinancial disclosures: The authors have no relevant conflicts of interest to disclose. ★ Conflict of interest: No conflicts of interest exist for any of the authors of this manuscript., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Although primary graft dysfunction (PGD) is a leading cause of mortality and morbidity early post-heart transplant, relatively little is known regarding mechanisms involved in PGD development., Methods and Results: We examined the relationship between cardiac troponin I (cTnI) concentrations in the preservation solution from 43 heart transplant procedures and the development of PGD. Donor hearts were flushed with cold preservation solution (University of Wisconsin [UW] or Custodiol) and stored in the same solution. cTnI concentrations were measured utilizing the i-STAT System and normalized to left ventricular mass. Recipient medical records were reviewed to determine PGD according to the 2014 ISHLT consensus conference. Nineteen patients developed PGD following cardiac transplantation. For both UW and Custodiol, normalized cTnI levels were significantly increased (P = .031 and .034, respectively) for those cases that developed PGD versus no PGD. cTnI levels correlated with duration of ischemic time in the UW group, but not for the Custodiol group. Donor age and donor cTnI (obtained prior to organ procurement) did not correlate with preservation cTnI levels in either UW or Custodiol., Conclusions: Increased preservation solution cTnI is associated with the development of PGD suggesting preservation injury may be a dominant mechanism for the development of PGD., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: With initiation of transcatheter aortic valve replacement (TAVR) programs, centers may see changes in surgical aortic valve replacement (SAVR) populations and related outcomes because of more high-risk patients undergoing TAVR rather than SAVR. Little data exist on the potential changes in the risk profiles and outcomes of SAVR patients from the pre- to post-TAVR eras. As such, this study sought to evaluate changes in the SAVR population at a tertiary referral center after TAVR program initiation., Methods: Using a single-center valve surgical database, annual volume, patient characteristics, operative details, and predicted and observed mortality for patients undergoing isolated SAVR or SAVR + coronary artery bypass grafting (CABG) from 2006 to 2013 were evaluated. Patients were divided into 3 eras: (1) pre-TAVR (January 2006-June 2009), (2) transition (July 2009-March 2011), and (3) TAVR (April 2011-June 2013). The primary analysis compared predicted and observed mortality in pre-TAVR and TAVR eras., Results: From 2006 to 2013, 1,380 SAVR patients were identified, with 505 (36.6%), 330 (23.9%), and 545 (39.5%) patients from the pre-TAVR, transition, and TAVR eras, respectively. SAVR case volume increased from 131 to 256 cases per year (95.4% increase) from the pre-TAVR to the post-TAVR eras. Predicted risk of mortality (PROM) for SAVR patients from the pre-TAVR to TAVR eras by The Society of Thoracic Surgeons (STS)-PROM was stable near 3.8% (p = 0.82). Crude 30-day SAVR mortality trended down from 2.8% in the pre-TAVR era to 1.5% in the post-TAVR era (p = 0.23)., Conclusions: Consistent with previous studies, initiation of a TAVR program was associated with increased SAVR volume. Risk profiles for SAVR patients in the TAVR era remained similar by the STS-PROM, indicating generally stable risk among surgical patients after launching a TAVR program. These data suggest that significant changes in the risk profiles of SAVR patients should not be expected with the initiation of a TAVR program. Further research will need to reevaluate these changes once TAVR becomes more widely available., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Bioprosthetic options are increasingly used for surgical aortic valve replacement (AVR). However, current decision making regarding bioprosthetic valve choice is not data-driven given incomplete information on comparative long-term outcomes after stented bovine pericardial (BoAVR) vs porcine (PoAVR) AVR. As such, this study sought to examine the effect of bioprosthetic valve choice on long-term survival and reoperation after AVR., Methods: A retrospective analysis of all stented bioprosthetic AVRs, with or without coronary artery bypass grafting procedures, at a single tertiary referral institution from 1980 to 2013 was conducted using a prospectively maintained database. Procedures were classified as BoAVR or PoAVR. The effect of valve type on long-term survival was assessed with Kaplan-Meier analysis and a Cox proportional hazard model. Subanalyses stratifying by valve size and patient age at the time of AVR assessing mortality and reoperation were also conducted., Results: We identified 2,010 stented bioprosthetic AVR patients, comprising 1,411 BoAVRs (70.2%) and 599 PoAVRs (29.8%), 868 (43.2%) of whom underwent concomitant coronary artery bypass grafting. Kaplan-Meier analysis (p = 0.12) and Cox models (hazard ratio BoAVR vs PoAVR, 1.08; p = 0.40) demonstrated no difference in long-term survival or need for reoperation after BoAVR vs PoAVR. Subanalyses of valve size and patient age also failed to show any association between valve choice and long-term survival or need for reoperation., Conclusions: For patients undergoing AVR with a stented bioprosthetic valve, with or without coronary artery bypass grafting, the choice of a porcine vs bovine pericardial bioprosthesis does not appear to affect long-term survival or need for reoperation, regardless of valve size or patient age. As such, stented bioprosthetic valves would appear to be fungible, and therefore, valve choice should be driven by local market factors similar to other commodities., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Even in the modern era of continuous-flow left ventricular assist devices (CF LVADs), device replacement may be required. Nonsternotomy (NS) approaches are being used more commonly for replacement procedures. Outcomes after this less invasive approach compared with those after a reoperative sternotomy (RS) have not been extensively studied. Furthermore, the clinical impact of concurrent cardiac procedures during device replacement has not been examined., Methods: From 2005 to 2013, all consecutive implantable LVAD procedures were reviewed, and those using CF devices as both the initial and replacement device were identified. These CF LVAD replacement procedures were divided into those using an RS and those using an NS approach. Periprocedural morbidity and mortality were compared between the groups., Results: A total of 42 CF LVAD replacements were performed in 39 patients, with 20 using an RS approach and 22 using an NS approach. Eleven of the 20 replacement procedures performed by RS included a concurrent cardiac procedure. Relative to the RS cohort, the NS approach was associated with shorter cardiopulmonary bypass time, reduced length of mechanical ventilation, decreased transfusion requirements, less inotropic support, decreased incidence of right ventricular (RV) dysfunction, and shorter intensive care unit (ICU) and overall hospital stays. An NS approach was also associated with improved 30- and 90-day survival (100% versus 79.0% in the RS group; p = 0.048). RS replacement procedures appeared to be associated with increased morbidity, regardless of whether they included concurrent cardiac procedures., Conclusions: Patients who did not require an RS approach and who underwent CF LVAD replacement through an NS approach had improved survival and reduced morbidity compared with those who required an RS., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Previous studies demonstrate that graft survival from older living kidney donors (LD; age>60 years) is worse than younger LD but similar to deceased standard criteria donors (SCD). Limited sample size has precluded more detailed analyses of transplants from older LD., Methods: Using the United Network for Organ Sharing database from 1994 to 2012, recipients were categorized by donor status: SCD, expanded criteria donor (ECD), or LD (by donor age: <60, 60-64, 65-69, ≥70 years). Adjusted models, controlling for donor and recipient risk factors, evaluated graft and recipient survivals., Results: Of 250,827 kidney transplants during the study period, 92,646 were LD kidneys, with 4.5% of these recipients (n=4,186) transplanted with older LD kidneys. The use of LD donors 60 years or older increased significantly from 3.6% in 1994 to 7.4% in 2011. Transplant recipients with older LD kidneys had significantly lower graft and overall survival compared to younger LD recipients. Compared to SCD recipients, graft survival was decreased in recipients with LD 70 years or older, but overall survival was similar. Older LD kidney recipients had better graft and overall survival than ECD recipients., Conclusions: As use of older kidney donors increases, overall survival among kidney transplant recipients from older living donors was similar to or better than SCD recipients, better than ECD recipients, but worse than younger LD recipients. With increasing kidney donation from older adults to alleviate profound organ shortages, the use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys.

Objective: The choice of cerebral perfusion strategy for aortic arch surgery has been debated, and the superiority of antegrade (ACP) or retrograde (RCP) cerebral perfusion has not been shown. We examined the early and late outcomes for ACP versus RCP in proximal (hemi-) arch replacement using deep hypothermic circulatory arrest (DHCA)., Methods: A retrospective analysis of a prospectively maintained database was performed for all patients undergoing elective and nonelective hemiarch replacement at a single referral institution from June 2005 to February 2013. Total arch cases were excluded to limit the analysis to shorter DHCA times and a more uniform patient population for whom clinical equipoise regarding ACP versus RCP exists. A total of 440 procedures were identified, with 360 (82%) using ACP and 80 (18%) using RCP. The endpoints included 30-day/in-hospital and late outcomes. A propensity score with 1:1 matching of 40 pre- and intraoperative variables was used to adjust for differences between the 2 groups., Results: All 80 RCP patients were propensity matched to a cohort of 80 similar ACP patients. The pre- and intraoperative characteristics were not significantly different between the 2 groups after matching. No differences were found in 30-day/in-hospital mortality or morbidity outcomes. The only significant difference between the 2 groups was a shorter mean operative time in the RCP cohort (P = .01). No significant differences were noted in late survival (P = .90)., Conclusions: In proximal arch operations using DHCA, equivalent early and late outcomes can be achieved with RCP and ACP, although the mean operative time is significantly less with RCP, likely owing to avoidance of axillary cannulation. Questions remain regarding comparative outcomes with straight DHCA and lesser degrees of hypothermia., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: A growing literature describes aneurysmal deterioration after implantation of the stentless porcine aortic Medtronic Freestyle bioprosthesis (MFB; Medtronic Inc, Minneapolis, MN), with some suggesting inadequate tissue fixation with immune response as a cause. However, disjointed reports make the significance of these findings difficult to interpret. We address this concern by aggregating available data., Methods: We reviewed institutional data, the Food and Drug Administration's Manufacturer and User Facility Device Experience registry, and the medical literature for mention of aneurysm or pseudoaneurysm after MFB. Case details were aggregated, and the rate of aneurysmal deterioration was estimated. Immunohistopathologic examination of institutional explanted specimens was performed to elucidate a cause., Results: We found 42 cases of aneurysmal deterioration with adequate detail for analysis; all occurred with full root replacement and valve sizes ranging from 23 to 29 mm. The rate of aneurysmal deterioration considering all data sources was 1.1% (9 of 851; 95% confidence interval, 0.5% to 2.0%) vs 4.7% (4 of 86; 95% confidence interval, 1.3% to 11.5%) at our institution, where yearly surveillance imaging is performed. Rate of aneurysmal deterioration appeared constant until 5 years after the operation; however, events are reported out to 10 years. Consistent with previous reports, histopathology demonstrated an immune cell infiltrate in areas of MFB wall breakdown., Conclusions: Aneurysmal deterioration is an increasingly described complication of MFB implantation as a full root, with an incidence as high as 4.7%. Given the observed immune reaction and lack of occurrence in smaller (19-mm and 21-mm) valve sizes, inadequate pressure fixation of larger valves is a potential etiology. Patients with MFB require annual surveillance imaging, and consideration of this complication should factor into preoperative decision making because treatment mandates redo root replacement, which may not be feasible in high-risk patients., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Thoracic endovascular aortic repair (TEVAR) for chronic DeBakey IIIb dissection with associated descending aneurysm remains controversial. This study examines long-term results of TEVAR for this disorder including examination of anatomic features associated with TEVAR outcomes., Methods: Between July 2005 and January 2013, 32 patients underwent TEVAR for chronic (>30 days) DeBakey IIIb dissection involving the descending thoracic aorta at a single institution and constituted the study cohort., Results: The mean interval from dissection to TEVAR was 32 ± 44 months (range, 1 to 146 months). There were no 30-day or in-hospital deaths, strokes, or paraplegia. During a 54-month median follow-up, there were no aortic-related deaths. Significant thoracic aneurysm sac regression (>1 cm) in the intervened segment was observed in 89%. Thoracic remodeling was not correlated with the number of visceral vessels arising from the true lumen or the number or size of residual distal fenestrations; failure of thoracic remodeling was associated with fenestrations distal to the endograft(s) in the descending thoracic aorta, most often stent graft-induced new entry tears. Complete resolution of the thoracic and abdominal false lumen after TEVAR was observed in 15.6% (n = 5). All patients in this group had all visceral vessels arising from the true lumen and fewer than three residual distal fenestrations., Conclusions: Thoracic endovascular aortic repair is effective for chronic DeBakey IIIb dissection with associated descending aneurysm, with excellent 30-day and long-term outcomes and significant aortic remodeling in the vast majority of patients. Thoracic remodeling does not appear dependent on distal anatomic characteristics of the true and false lumens, although care should be taken to cover all thoracic fenestrations and avoid creation of stent graft-induced new entry tears to ensure clinical success. Complete aortic remodeling was observed only in the setting of all visceral vessels off the true lumen with fewer than three residual distal fenestrations, and this would appear the ideal anatomy for TEVAR in this scenario., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Patients with thoracic aortic disease undergoing thoracic endovascular aortic repair (TEVAR) often have concomitant coronary artery disease and are at risk for perioperative adverse cardiac events. Despite this risk, the need for and extent of preoperative cardiac workup before TEVAR remain undefined. This study seeks to assess the adequacy of a limited cardiac evaluation before TEVAR, including assessment of cardiac symptoms, resting electrocardiography (ECG), and transthoracic echocardiography (TTE), as well as to estimate the incidence of perioperative cardiac events in patients undergoing TEVAR., Methods: Retrospective analysis of a prospectively maintained Institutional Review Board-approved database was performed for all patients undergoing TEVAR at a single referral institution between May 2002 and June 2013. The analysis identified 463 TEVAR procedures. All procedures involving median sternotomy were excluded, and 380 procedures (343 patients) were included in the final analysis. Degree of cardiac workup was classified on the basis of the highest level of preoperative testing: no workup, resting ECG only, resting TTE, exercise/pharmacologic stress testing, or coronary angiography. Standard workup consisted of cardiac symptom assessment along with resting ECG or TTE, with further workup indicated for unstable symptoms, significantly abnormal findings on ECG or TTE, or multiple cardiac risk factors. Categorical and continuous variables were compared by Fisher's exact test and analysis of variance, respectively., Results: No preoperative cardiac workup was performed for 28 patients (7.4%); 127 patients (33.4%) had resting ECG only, 208 patients (54.7%) had resting echocardiography, 12 patients (3.2%) underwent stress testing, and five patients (1.3%) had coronary angiography. Patients undergoing stress testing or coronary angiography were older and had a higher incidence of known coronary artery disease (P < .01) and prior myocardial infarction (P = .01). Complex hybrid aortic repairs and TEVAR for aneurysmal disease were more likely to have an extensive workup, whereas nonelective procedures more commonly had no workup. A total of nine patients (2.4%) experienced a perioperative cardiac event (myocardial infarction or cardiac arrest), with no significant difference noted among all groups (P = .45), suggesting that the extent of cardiac workup was appropriate. The incidence of 30-day/in-hospital mortality (5.5%) and cardiac-specific mortality (0.8%) was similar among all groups., Conclusions: The risk of a postoperative cardiac event after TEVAR is low (2.4%), and initial screening with either resting TTE or ECG, in addition to assessment of cardiac symptom status, appears adequate for most TEVAR patients. As such, we recommend resting TTE or ECG as the initial cardiovascular screening mechanism in patients undergoing TEVAR, with subsequent more invasive studies if initial screening reveals cardiovascular abnormalities., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Aortic insufficiency (AI) in patients supported with continuous-flow left ventricular assist devices (CF-LVAD) results in regurgitant volume returning from the aorta to the left ventricle, increased LVAD pump volume and reduced systemic cardiac output. One common strategy to address AI during CF-LVAD support is central oversewing of the aortic valve, which allows some opening between the valve leaflets laterally. However, the long-term durability of this technique has not been extensively described., Methods: All patients who underwent central oversewing of the aortic valve during CF-LVAD support between January 2006 and March 2013 were included in this analysis. Pre- and post-procedure intra-operative transesophageal echocardiograms (TEEs) were reviewed to determine the efficacy of the surgical technique, whereas all subsequent transthoracic echocardiograms (TTEs) were reviewed to assess durability. AI severity was graded using the vena contracta (VC) width and the ratio between the VC and left ventricular outflow tract (LVOT) diameter., Results: Nineteen patients with central aortic valve oversewing were identified. Median follow-up was 560 days (range 46 to 954 days). All but 1 patient had their aortic insufficiency reduced to "none/trace" on post-operative TEE. There was no statistically significant increase in the VC width and VC/LVOT ratio between the first and last follow-up echocardiograms, and only 2 patients developed more than mild aortic insufficiency after central oversewing. Central oversewing of the aortic valve did not adversely affect outcomes after LVAD implantation., Conclusion: Central oversewing of the aortic valve is an effective and durable means of addressing greater than mild AI in patients with CF-LVAD., (Copyright © 2014 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

The molecular differences between ischemic (IF) and non-ischemic (NIF) heart failure are poorly defined. A better understanding of the molecular differences between these two heart failure etiologies may lead to the development of more effective heart failure therapeutics. In this study extensive proteomic and phosphoproteomic profiles of myocardial tissue from patients diagnosed with IF or NIF were assembled and compared. Proteins extracted from left ventricular sections were proteolyzed and phosphopeptides were enriched using titanium dioxide resin. Gel- and label-free nanoscale capillary liquid chromatography coupled to high resolution accuracy mass tandem mass spectrometry allowed for the quantification of 4,436 peptides (corresponding to 450 proteins) and 823 phosphopeptides (corresponding to 400 proteins) from the unenriched and phospho-enriched fractions, respectively. Protein abundance did not distinguish NIF from IF. In contrast, 37 peptides (corresponding to 26 proteins) exhibited a ≥ 2-fold alteration in phosphorylation state (p<0.05) when comparing IF and NIF. The degree of protein phosphorylation at these 37 sites was specifically dependent upon the heart failure etiology examined. Proteins exhibiting phosphorylation alterations were grouped into functional categories: transcriptional activation/RNA processing; cytoskeleton structure/function; molecular chaperones; cell adhesion/signaling; apoptosis; and energetic/metabolism. Phosphoproteomic analysis demonstrated profound post-translational differences in proteins that are involved in multiple cellular processes between different heart failure phenotypes. Understanding the roles these phosphorylation alterations play in the development of NIF and IF has the potential to generate etiology-specific heart failure therapeutics, which could be more effective than current therapeutics in addressing the growing concern of heart failure.

Since its introduction in the late 19(th) century, the Langendorff isolated heart perfusion apparatus, and the subsequent development of the working heart model, have been invaluable tools for studying cardiovascular function and disease(1-15). Although the Langendorff heart preparation can be used for any mammalian heart, most studies involving this apparatus use small animal models (e.g., mouse, rat, and rabbit) due to the increased complexity of systems for larger mammals(1,3,11). One major difficulty is ensuring a constant coronary perfusion pressure over a range of different heart sizes - a key component of any experiment utilizing this device(1,11). By replacing the classic hydrostatic afterload column with a centrifugal pump, the Langendorff working heart apparatus described below allows for easy adjustment and tight regulation of perfusion pressures, meaning the same set-up can be used for various species or heart sizes. Furthermore, this configuration can also seamlessly switch between constant pressure or constant flow during reperfusion, depending on the user's preferences. The open nature of this setup, despite making temperature regulation more difficult than other designs, allows for easy collection of effluent and ventricular pressure-volume data.

As the duration of support increases for patients with continuous flow left ventricular assist devices (LVADs), device replacement may still be necessary for a variety of indications. Outcomes after replacement LVAD surgeries have not been extensively described, and whether these patients experience outcomes similar to primary LVAD implant patients remains unclear. From 2003 to 2012, 342 consecutive implantable LVAD procedures took place at a single institution, of which 201 were considered destination therapy. Within this larger group, 30 patients underwent 35 replacement procedures. The three major indications for replacement LVAD procedures were mechanical/electrical failure (57%), hemolysis/thrombosis (29%), and infection (14%). Propensity matching using preoperative characteristics was used to generate a primary implant control group to determine the impact of the replacement status on outcomes. Thirty-day and 1-year survival after LVAD replacement was 90% and 48%, respectively. Survival outcomes were worse for patients undergoing device replacement compared with the matched primary cohort (p = 0.03). The need for transfusion and the incidence of postoperative right ventricular and renal dysfunction were similar between the two groups, as was length of hospitalization. There was no difference between the rates of postoperative infection or stroke. Emergent replacement procedures had a higher mortality than those done nonemergently. Given these findings, earlier timing for replacement, temporary stabilization with an extracorporeal device, and use of a nonsternotomy surgical approach should be investigated as strategies to improve outcomes.

Objectives: Although frailty has recently been examined in various populations as a predictor of morbidity and mortality, its effect on thoracic aortic surgery outcomes has not been studied. The objective of the present study was to evaluate the role of frailty in predicting postoperative morbidity and mortality in patients undergoing proximal aortic replacement surgery., Methods: A retrospective analysis of a prospectively maintained database was performed for all patients undergoing elective and nonelective proximal aortic operations (root, ascending aorta, and/or arch) at a single-referral institution from June 2005 to December 2012. A total of 581 patients underwent proximal aortic surgery, of whom 574 (98.8%) were included in the present analysis; 7 were excluded because of incomplete data. Frailty was evaluated using an index consisting of age >70 years, body mass index <18.5 kg/m(2), anemia, history of stroke, hypoalbuminemia, and total psoas volume in the bottom quartile of the population. One point was given for each criterion met to determine a frailty score of 0 to 6. Frailty was defined as a score of ≥2. Risk models for length of stay >14 days, discharge to other than home, 30-day composite major morbidity, 30-day composite major morbidity/mortality, and 30-day and 1-year mortality were calculated using multivariate regression modeling., Results: Of the 574 patients, 148 (25.7%) were defined as frail (frailty score ≥2). The unadjusted 30-day/in-hospital and long-term outcomes were significantly worse for the frail versus nonfrail patients in all but 1 of the outcomes analyzed; no difference was found in the 30-day readmission rates between the 2 groups. In the multivariate model, a frailty score of ≥2 was associated with discharge to other than home and 30-day and 1-year mortality., Conclusions: Frailty, as defined using a 6-component frailty index, can serve as an independent predictor of discharge disposition and early and late mortality risk in patients undergoing proximal aortic surgery. These frailty markers, all of which are easily assessed preoperatively, could provide valuable information for patient counseling and risk stratification before proximal aortic replacement., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: Aortic valve regurgitation reduces left ventricular assist device mechanical efficiency. Evidence has also suggested that left ventricular assist device implantation can induce or exacerbate aortic valve regurgitation. However, this has not been compared with aortic valve regurgitation progression in a nonsurgical end-stage heart failure population. Furthermore, its clinical effect is unclear. We sought to characterize the development and progression of aortic valve regurgitation in left ventricular assist device recipients and to identify its clinical effect., Methods: A review of all consecutive patients who received an intracorporeal left ventricular assist device at Duke University Medical Center from January 2004 to January 2011 was conducted. Cases of previous or concomitant aortic valve surgery were excluded. Data from the remaining implants (n = 184) and a control group of contemporaneous nonsurgical patients with end-stage heart failure (n = 132) were analyzed. Serial transthoracic echocardiography was used to characterize aortic valve regurgitation as a function of time., Results: Left ventricular assist device implantation was associated with worsening aortic valve regurgitation, defined as an increase in aortic valve regurgitation grade, relative to the nonsurgical patients with end-stage heart failure (P < .0001). The recipients of continuous flow left ventricular assist devices were more likely than recipients of pulsatile left ventricular assist devices to develop worsening aortic valve regurgitation (P = .0348). Moderate or severe aortic valve regurgitation developed in 21 left ventricular assist device recipients; this was unrelated to the type of device implanted (continuous vs pulsatile; P = .754) or aortic valve regurgitation grade before left ventricular assist device implantation (P = .42). Five patients developed severe aortic valve regurgitation; all of whom underwent aortic valve procedures., Conclusions: Native aortic valve regurgitation developed and/or progressed after left ventricular assist device implantation, with this effect being more pronounced in continuous flow left ventricular assist device recipients. However, the preoperative aortic valve regurgitation grade failed to correlate with the development of substantial aortic valve regurgitation after left ventricular assist device implantation. After left ventricular assist device implantation, aortic valve regurgitation had a small, but discernible, clinical effect, with some patients developing severe aortic valve regurgitation and requiring aortic valve procedures. These data have implications for the long-term management of left ventricular assist device recipients, in particular as the durability of implantable continuous flow left ventricular assist device therapy improves., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Malposition, embolization, fracture, and migration of endovascular devices are unfortunate consequences of endovascular intervention and will be encountered at some point by nearly every practitioner. The existing literature on foreign body retrieval consists of large single-institution series and case reports. We provide an overview of this recent literature, clarifying what devices are being lost, what symptoms occur as a result, and how retrieval is being performed. We have identified all case series and case reports since the year 2000, summarized the results, and made some general observations and recommendations that may be useful to the practitioner faced with the prospect of retrieving a fractured medical device, malpositioned coil, or migrated inferior vena cava filter., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: The ideal anesthetic technique for carotid endarterectomy remains a matter of debate. This study used the American College of Surgeons National Surgical Quality Improvement Program to evaluate the influence of anesthesia modality on outcomes after carotid endarterectomy., Methods: Postoperative outcomes were compared for American College of Surgeons National Surgical Quality Improvement Program patients undergoing carotid endarterectomy between 2005 and 2009 with either general or regional anesthesia. A separate analysis was performed on a subset of patients matched on propensity for undergoing carotid endarterectomy with regional anesthesia., Results: For the entire sample of 24,716 National Surgical Quality Improvement Program patients undergoing carotid endarterectomy and the propensity-matched cohort of 8,050 patients, there was no difference in the 30-day postoperative composite stroke/myocardial infarction/death rate based on anesthetic type. Within the matched cohort, the rate of other complications did not differ (2.8% regional vs. 3.6% general anesthesia; P = .07), but patients receiving regional anesthesia had shorter operative (99 ± 36 minutes vs 119 ± 53 minutes; P < .0001) and anesthesia times (52 ± 29 minutes vs. 64 ± 37 minutes; P < .0001) and were more likely to be discharged the next day (77.0% vs 64.4%; P < .0001)., Conclusion: Anesthesia technique does not impact patient outcomes after carotid endarterectomy, but may influence overall cost of care., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Progressive Audiologic Tinnitus Management (PATM) is based on the premise that tinnitus is managed most efficiently using a hierarchy of clinical services that address different levels of need. PATM includes five levels of management: (a) triage; (b) audiologic evaluation; (c) group education; (d) tinnitus evaluation; and (e) individualized management. This article provides an overview of PATM and focuses on the procedures that make up the Level 2 Audiologic Evaluation. The evaluation is conducted to assess the potential need for medical, audiologic (hearing loss, tinnitus, hyperacusis), and/or mental health services. The Tinnitus Handicap Inventory, Hearing Handicap Inventory, and Tinnitus and Hearing Survey are used to differentiate effects of tinnitus and hearing loss. If indicated, patients are interviewed with the Tinnitus-Impact Screening Interview. Patients requiring amplification receive hearing aids. Often, management of hearing loss at Level 2 addresses any problems that were attributed to the tinnitus, which obviates further tinnitus-specific intervention.

Management of tinnitus generally involves educational counseling, stress reduction, and/or the use of therapeutic sound. This article focuses on therapeutic sound, which can involve three objectives: (a) producing a sense of relief from tinnitus-associated stress (using soothing sound); (b) passively diverting attention away from tinnitus by reducing contrast between tinnitus and the acoustic environment (using background sound); and (c) actively diverting attention away from tinnitus (using interesting sound). Each of these goals can be accomplished using three different types of sound-broadly categorized as environmental sound, music, and speech-resulting in nine combinations of uses of sound and types of sound to manage tinnitus. The authors explain the uses and types of sound, how they can be combined, and how the different combinations are used with Progressive Audiologic Tinnitus Management. They also describe how sound is used with other sound-based methods of tinnitus management (Tinnitus Masking, Tinnitus Retraining Therapy, and Neuromonics).

A controlled clinical study was conducted to evaluate prospectively the clinical efficacy of tinnitus masking (TM) and tinnitus retraining therapy (TRT) in military veterans having clinically significant tinnitus. Qualifying patients were placed into the two groups in an alternating manner (to avoid selection bias), and treatment was administered at 0, 3, 6, 12, and 18 months. Outcomes of treatment were evaluated using three self-administered tinnitus questionnaires (Tinnitus Handicap Inventory, Tinnitus Handicap Questionnaire, Tinnitus Severity Index) and the verbally administered TRT interview forms. Findings are presented from the three written questionnaires, and from two of the interview questions (percentage time aware of, and annoyed by, tinnitus). Outcomes were analyzed on an intent-to-treat basis, using a multilevel modeling approach. Of the 123 patients enrolled, 118 were included in the analysis. Both groups showed significant declines (improvements) on these measures, with the TRT decline being significantly greater than for TM. The greater declines in TRT compared to TM occurred most strongly in patients who began treatment with a "very big" tinnitus problem. When patients began treatment with a "moderate" tinnitus problem, the benefits of TRT compared to TM were more modest.

Tinnitus is an increasing health concern across all strata of the general population. Although an abundant amount of literature has addressed the many facets of tinnitus, wide-ranging differences in professional beliefs and attitudes persist concerning its clinical management. These differences are detrimental to tinnitus patients because the management they receive is based primarily on individual opinion (which can be biased) rather than on medical consensus. It is thus vitally important for the tinnitus professional community to work together to achieve consensus. To that end, this article provides a broad-based review of what is presently known about tinnitus, including prevalence, associated factors, theories of pathophysiology, psychological effects, effects on disability and handicap, workers' compensation issues, clinical assessment, and various forms of treatment. This summary of fundamental information has relevance to both clinical and research arenas.

Chronic tinnitus is experienced by 10%-15% of the population, of which only about 20% require clinical intervention. People requiring intervention have different levels of need, ranging from the provision of basic information to long-term, individualized treatment. We address this clinical need by outlining a five-level "progressive intervention" approach to the management of tinnitus that would provide a systematic framework for treatment by audiologists. At each level, patients must be appropriately referred-usually to otolaryngology, psychology, and/or psychiatry. Level 1 is an interview method of screening for determining if the person requires clinical intervention (and addressing basic questions). Level 2 is the provision of structured group educational counseling. If the screening determines that care is urgently required or if further help is needed following the group session(s), a tinnitus intake assessment (Level 3) should be performed. The intake assessment, which includes educational counseling, can often meet a patient's needs. If not, then a program of continuing treatment (Level 4) would be indicated. If significant benefit were not achieved through consistent treatment over 1-2 years, longer-term treatment (Level 5) would be indicated, which could include alternate or multiple treatment modalities. At all levels, the goal is to minimize the impact of tinnitus on the patient's life as efficiently as possible.

Purpose: This article is the first of 2 that present basic guidelines for audiologists to provide clinical management of tinnitus. The method, termed audiologic tinnitus management (ATM), was developed to incorporate management strategies that can be implemented most efficiently by audiologists., Method: Development of ATM has been drawn from the clinical and research experience of the authors and numerous audiologists. Certain elements of ATM are adapted from the methods of tinnitus masking and tinnitus retraining therapy. Procedures are described in the present article for performing the intake assessment, while the companion article (J. A. Henry, T. L. Zaugg, & M. A. Schechter, 2005) describes treatment methodology., Results: Development of ATM has resulted in defined procedures to conduct a basic tinnitus assessment that includes written questionnaires, an intake interview, audiologic evaluation, and a psychoacoustic assessment of tinnitus perceptual characteristics. If patients report a sound tolerance problem (hyperacusis), loudness discomfort levels are measured at audiometric frequencies. There are special procedures for selecting hearing aids, ear-level noise generators, combination devices (noise generator and hearing aid combined), and personal listening devices (i.e., portable radios and tape, CD, and MP3 players)., Conclusions: This article explains each of these assessment components in detail. Adoption of the ATM assessment protocol by audiologists can contribute to the establishment of uniform procedures for the clinical management of tinnitus patients.

Purpose: This article is the second of 2 that address the need for basic procedures that can be used commonly by audiologists to manage patients with clinically significant tinnitus, as well as hyperacusis. The method described is termed audiologic tinnitus management (ATM)., Method: ATM was developed specifically for use by audiologists. Although certain procedural components were adapted from the methods of tinnitus masking and tinnitus retraining therapy, ATM is uniquely and specifically defined. A detailed description of the ATM assessment procedures is provided in the companion article (J. A. Henry, T. L. Zaugg, & M. A. Schechter, 2005). The present article describes a specific clinical protocol for providing treatment with ATM., Results: The treatment method described for ATM includes structured informational counseling and an individualized program of sound enhancement that can include the use of hearing aids, ear-level noise generators, combination instruments (noise generator and hearing aid combined), personal listening devices (wearable CD, tape, and MP3 players), and augmentative sound devices (e.g., tabletop sound generators). Ongoing treatment appointments involve primarily the structured counseling, evaluation, and adjustment of the use of sound devices, and assessment of treatment outcomes. The informational counseling protocol and an interview form for determining treatment outcomes are each described in step-by-step detail for direct clinical application., Conclusion: This article can serve as a practical clinical guide for audiologists to provide treatment for tinnitus in a uniform manner.

Tinnitus Retraining Therapy (TRT) is a structured method of tinnitus treatment that has been performed since 1990. The TRT Initial Interview form was developed to guide clinicians in obtaining essential information from patients that would specify treatment needs. The TRT Follow-up Interview form is similar to the initial interview form and is designed to evaluate outcomes of treatment. The clinician administers these forms verbally. The forms have been used in a highly abbreviated format with the potential for inconsistent interview administration between examiners. This project was to expand the forms to provide specific wording for each question. The expanded forms are presented in this article, and the intent of each question is explained. Standardized administration of these interview forms will facilitate greater uniformity in the initial evaluation and outcomes analyses of patients treated with TRT.

This article presents high-frequency (8- to 20-kHz) auditory threshold measurements for 157 subjects with normal conventional hearing, ranging in age from 6-30 years. Normative descriptive data are provided in five semidecade age categories. Intra-age category mean and variance values for threshold sensitivity and interaural threshold differences are included. Generally, the data are consistent with the expectation of a gradual diminution of high-frequency sensitivity through the adolescent and early adult years. Several unresolved issues related to high-frequency normative data and clinical applicability of high-frequency threshold measurements are discussed.

High-frequency (8 to 20 kHz) hearing sensitivity was compared in thirty-six, 20 to 29-year-old military veterans with histories of steady-state or impulsive noise exposure. Threshold shifts were prominent for the steady-state noise subjects from 13 to 20 kHz. Mean thresholds from 8 through 12 kHz were maximally 20 dB poorer than a sample of young adult normals. Audiometric configurations for this group were generally smooth and symmetrical above 8000 Hz. For the impulsive noise group, substantial shifts in sensitivity were seen from 2 to 20 kHz and the high-frequency audiometric configurations were often jagged and/or asymmetrical. The variability of subjects in this group was greater than that seen in the steady-state noise exposed sample. Several case studies are presented to illustrate these characteristics. Measurement of auditory sensitivity from 8 to 20 kHz extends the mapping of basal cochlear function, providing information which often is not predictable from conventional audiometric measurement. This additional information provides for more comprehensive inter- and intra-subject comparison of the degree and extent of threshold changes present.

A recently developed high frequency auditory measurement technique was applied to a sample of patients receiving the antineoplastic agent cis-dichlorodiammineplatinum II (cisplatin [CDDP, DDP]). Ototoxicity as a result of cisplatin administration is well documented. The ability to detect ototoxicity, however, varies with the methods and instrumentation utilized, and the criteria by which ototoxicity is defined. The auditory function of subjects receiving cisplatin for genitourinary tumors and head and neck cancers was serially monitored with conventional audiometry and with a high frequency testing system. Results reveal a high incidence of nonreversible cochlear toxicity with a predilection for involvement of the higher frequencies. Cochlear toxicity was detected earlier with the high frequency evaluation system than with conventional audiometry. The case reports presented are characteristic of the type and magnitude of auditory changes observed.