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Nkonde-Price C, Reynolds K, Najem M, Yang SJ, Batiste C, Cotter T, Lahti D, Gin N, Funahashi T. Comparison of Home-Based vs Center-Based Cardiac Rehabilitation in Hospitalization, Medication Adherence, and Risk Factor Control Among Patients With Cardiovascular Disease. JAMA Netw Open 2022; 5:e2228720. [PMID: 36006642 PMCID: PMC9412228 DOI: 10.1001/jamanetworkopen.2022.28720] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Prior studies have suggested that participation in home-based cardiac rehabilitation (HBCR) vs center-based cardiac rehabilitation (CBCR) results in similar clinical outcomes in patients with low to moderate risk; however, outcome data from demographically diverse populations and patients who are medically complex are lacking. OBJECTIVE To compare hospitalizations, medication adherence, and cardiovascular risk factor control between participants in HBCR vs CBCR. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted among patients in Kaiser Permanente Southern California (KPSC), an integrated health care system serving approximately 4.7 million patients, who participated in CR between April 1, 2018, and April 30, 2019, and with follow-up through April 30, 2020. Data were analyzed from January 2021 to January 2022. EXPOSURES Participation in 1 or more HBCR or CBCR sessions. MAIN OUTCOMES AND MEASURES The primary outcome was 12-month all-cause hospitalization. Secondary outcomes included all-cause hospitalizations at 30 and 90 days; 30-day, 90-day, and 12-month cardiovascular hospitalizations; and medication adherence and cardiovascular risk factor control at 12 months. Logistic regression was used to compare hospitalization, medication adherence, and cardiovascular risk factor control, with inverse probability treatment weighting (IPTW) to adjust for demographic and clinical characteristics. RESULTS Of 2556 patients who participated in CR (mean [SD] age, 66.7 [11.2] years; 754 [29.5%] women; 1196 participants [46.8%] with Charlson Comorbidity Index ≥4), there were 289 Asian or Pacific Islander patients (11.3%), 193 Black patients (7.6%), 611 Hispanic patients (23.9%), and 1419 White patients (55.5%). A total of 1241 participants (48.5%) received HBCR and 1315 participants (51.5%) received CBCR. After IPTW, patients who received HBCR had lower odds of hospitalization at 12 months (odds ratio [OR], 0.79; 95% CI, 0.64-0.97) but similar odds of adherence to β-blockers (OR, 1.18; 95% CI, 0.98-1.42) and statins (OR, 1.02; 95% CI, 0.84-1.25) and of control of blood pressure (OR, 0.98; 95% CI, 0.81-1.17), low-density lipoprotein cholesterol (OR, 0.98; 95% CI, 0.81-1.20), and hemoglobin A1c (OR, 0.98; 95% CI, 0.82-1.18) at 12 months compared with patients who received CBCR. CONCLUSIONS AND RELEVANCE These findings suggest that HBCR in a demographically diverse population, including patients with high risk who are medically complex, was associated with fewer hospitalizations at 12 months compared with patients who participated in CBCR. This study strengthens the evidence supporting HBCR in previously understudied patient populations.
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Affiliation(s)
- Chileshe Nkonde-Price
- Department of Cardiology, Kaiser Permanente West Los Angeles Medical Center, Los Angeles, California
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
- Southern California Permanente Medical Group, Pasadena
| | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Michael Najem
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Su-Jau Yang
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Columbus Batiste
- Southern California Permanente Medical Group, Pasadena
- Department of Cardiology, Kaiser Permanente Riverside Medical Center, Los Angeles, California
- Kaiser Permanente Center for Health Innovation, Tustin, California
| | - Timothy Cotter
- Southern California Permanente Medical Group, Pasadena
- Department of Cardiology, Kaiser Permanente Baldwin Park Medical Center, Los Angeles, California
| | - Debora Lahti
- Kaiser Permanente Center for Health Innovation, Tustin, California
| | - Nancy Gin
- Southern California Permanente Medical Group, Pasadena
- Kaiser Permanente Center for Health Innovation, Tustin, California
| | - Tadashi Funahashi
- Southern California Permanente Medical Group, Pasadena
- Kaiser Permanente Center for Health Innovation, Tustin, California
- Department of Orthopedic Surgery, Kaiser Permanente Orange County Medical Center, Anaheim, California
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Aggarwal M, Ros E, Allen K, Sikand G, Agarwala A, Aspry K, Kris-Etherton P, Devries S, Reddy K, Singh T, Litwin SE, Keefe JO, Miller M, Andrus B, Blankstein R, Batiste C, Belardo D, Wenger C, Batts T, Barnard ND, White BA, Ornish D, Williams KA, Ostfeld RJ, Freeman AM. Controversial Dietary Patterns: A High Yield Primer for Clinicians. Am J Med 2022; 135:680-687. [PMID: 35134371 DOI: 10.1016/j.amjmed.2022.01.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/06/2022] [Accepted: 01/09/2022] [Indexed: 12/20/2022]
Abstract
In cardiology clinic visits, the discussion of optimal dietary patterns for prevention and management of cardiovascular disease is usually very limited. Herein, we explore the benefits and risks of various dietary patterns, including intermittent fasting, low carbohydrate, Paleolithic, whole food plant-based diet, and Mediterranean dietary patterns within the context of cardiovascular disease to empower clinicians with the evidence and information they need to maximally benefit their patients.
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Affiliation(s)
| | - Emilio Ros
- Lipid Clinic, Endocrinology and Nutrition Service, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Barcelona and Ciber Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | | | - Geeta Sikand
- Heart Disease Prevention Program, University of California Irvine
| | - Anandita Agarwala
- Cardiovascular Division, Baylor Scott and White the Heart Hospital - Plano, Texas
| | - Karen Aspry
- Division of Cardiology, Lifespan Cardiovascular Institute, East Providence, RI; Brown University, Providence, RI
| | - Penny Kris-Etherton
- Department of Nutritional Sciences, Penn State University, University Park, Pa
| | - Stephen Devries
- Gaples Institute for Integrative Cardiology, Deerfield, Ill; Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Koushik Reddy
- Division of Cardiology, James A Haley VA Medical Center, University of South Florida, Tampa
| | - Tamanna Singh
- Division of Cardiovascular Medicine, Heart, Vascular, Thoracic Institute Cleveland Clinic, Ohio
| | - Sheldon E Litwin
- Division of Cardiology, Medical University of South Carolina, Charleston; Division of Cardiology, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
| | - James O' Keefe
- Saint Luke's Mid America Heart Institute, Kansas City, Mo
| | - Michael Miller
- Division of Cardiology, University of Maryland School of Medicine, Baltimore
| | - Bruce Andrus
- Division of Cardiology, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Ron Blankstein
- Division of Cardiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Columbus Batiste
- Division of Cardiology, Kaiser Permanente Riverside Medical Center, Charleston, SC
| | | | | | - Travis Batts
- Division of Cardiology, Department of Medicine, Wilford Hall Ambulatory Surgical Center, San Antonio, Texas
| | - Neal D Barnard
- George Washington University School of Medicine, Washington, DC; Physicians Committee for Responsible Medicine, Washington, DC
| | - Beth A White
- Division of Cardiology Marshall Health, Joan C. Edward School of Medicine, Huntington, WV
| | - Dean Ornish
- Preventive Medicine Research Institute, Sausalito, Calif; University of California, San Francisco
| | - Kim A Williams
- Division of Cardiology, Rush University Medical Center, Chicago, Ill
| | | | - Andrew M Freeman
- Division of Cardiology, Department of Medicine, National Jewish Health, Denver, Colo
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3
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Aggarwal M, Freeman AM, Ros E, Allen K, Sikand G, Aspry K, Kris-Etherton P, Devries S, Reddy K, Singh T, Litwin SE, O'Keefe J, Miller M, Andrus B, Blankstein R, Batiste C, Belardo D, Wenger C, Batts T, Barnard ND, White BA, Ornish D, Williams KA, Ostfeld RJ. Trending Nutrition Controversies #3: Top Controversies in 2021. Am J Med 2022; 135:146-156. [PMID: 34509452 DOI: 10.1016/j.amjmed.2021.07.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 12/27/2022]
Abstract
Each year, patients are bombarded with diverging and even contradictory reports concerning the impact of certain additives, foods, and nutrients on cardiovascular health and its risk factors. Accordingly, this third review of nutrition controversies examines the impact of artificial sweeteners, cacao, soy, plant-based meats, nitrates, and meats from grass compared to grain-fed animals on cardiovascular and other health outcomes with the goal of optimizing clinician-led diet counseling.
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Affiliation(s)
| | - Andrew M Freeman
- Division of Cardiology, Department of Medicine, National Jewish Health, Denver, Colo
| | - Emilio Ros
- Lipid Clinic, Endocrinology and Nutrition Service, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, Barcelona and Ciber Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | | | - Geeta Sikand
- Heart Disease Prevention Program, University of California Irvine, Irvine
| | - Karen Aspry
- Division of Cardiology, Lifespan Cardiovascular Institute, and Brown University, Providence, RI
| | | | - Stephen Devries
- Gaples Institute for Integrative Cardiology, Deerfield, Ill; Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Koushik Reddy
- Division of Cardiology, James A Haley VA Medical Center, University of South Florida, Tampa
| | - Tamanna Singh
- Division of Cardiovascular Medicine, Heart, Vascular, Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sheldon E Litwin
- Division of Cardiology, University of South Carolina, Charleston; Ralph H Johnson Veterans Affairs Medical Center, Charleston, SC
| | - James O'Keefe
- Saint Luke's Mid America Heart Institute, Kansas City, Mo
| | - Michael Miller
- Division of Cardiology, University of Maryland School of Medicine, Baltimore
| | - Bruce Andrus
- Division of Cardiology, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Ron Blankstein
- Division of Cardiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Columbus Batiste
- Division of Cardiology, Kaiser Permanente Riverside Medical Center, Riverside, Calif
| | | | | | - Travis Batts
- Division of Cardiology, Department of Medicine, Wilford Hall Ambulatory Surgical Center, San Antonio, Tex
| | - Neal D Barnard
- Adjunct Faculty, George Washington University School of Medicine, Washington, DC; Physici Committee for Responsible Medicine, Washington, DC
| | - Beth A White
- Division of Cardiology, Marshall Health/Joan C. Edward School of Medicine, Huntington, WV
| | - Dean Ornish
- Preventive Medicine Research Institute, Sausalito, Calif; Deparment of Medicine, University of California, San Francisco, San Francisco
| | - Kim A Williams
- Division of Cardiology, Rush University Medical Center, Chicago, Ill
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4
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Ostfeld RJ, Allen KE, Aspry K, Brandt EJ, Spitz A, Liberman J, Belardo D, O'Keefe JH, Aggarwal M, Miller M, Batiste C, Kopecky S, White B, Shah N, Hawamdeh H, Batts T, Blankstein R, Reddy K, Ornish D, Freeman AM. Vasculogenic Erectile Dysfunction: The Impact of Diet and Lifestyle. Am J Med 2021; 134:310-316. [PMID: 33227246 DOI: 10.1016/j.amjmed.2020.09.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 12/15/2022]
Abstract
Vasculogenic erectile dysfunction has been aptly called the "canary in the coal mine" for cardiovascular disease because it almost always precedes other manifestations of atherosclerotic cardiovascular disease, including myocardial infarction and stroke. It is common, associated with the presence of modifiable cardiovascular risk factors, and impacted by diet and lifestyle choices. This concise review provides an update on the use of dietary and other lifestyle interventions to improve vasculogenic erectile dysfunction and atherosclerotic cardiovascular disease.
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Affiliation(s)
| | | | - Karen Aspry
- Lifespan Cardiovascular Institute, and Department of Medicine, Division of Cardiology, Brown University, Alpert Medical School, Providence, RI
| | - Eric J Brandt
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Aaron Spitz
- Partner, Orange County Urology Associates, Volunteer Clinical Assistant Professor, University of California, Irvine Department of Urology, Orange
| | - Joshua Liberman
- Ascension Wisconsin Cardiovascular Specialists, Milwaukee, Wis
| | - Danielle Belardo
- Division of Cardiology, Lankenau Medical Center, Wynnewood, Penn
| | - James H O'Keefe
- Medical Director of the Charles and Barbara Duboc Cardio Health & Wellness Center, Saint Luke's Mid America Heart Institute, Kansas City, Mo
| | | | - Michael Miller
- Professor of Cardiovascular Medicine, Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore
| | - Columbus Batiste
- Division of Cardiology, Kaiser Permanente Riverside and Moreno Valley, Riverside, Calif
| | - Stephen Kopecky
- Division of Cardiology, Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minn
| | - Beth White
- Department of Cardiology and Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, WV
| | - Nikhil Shah
- Division of Cardiology, University of Florida, Gainesville
| | | | - Travis Batts
- Division of Cardiology, Department of Medicine, Wilford Hall Ambulatory Surgical Center, San Antonio, Tex
| | - Ron Blankstein
- Division of Cardiology, Brigham and Women's Hospital, Boston, Mass
| | - Koushik Reddy
- Division of Cardiology, James A. Haley VA Medical Center, Tampa, Fla
| | - Dean Ornish
- Clinical Professor of Medicine, University of California, San Francisco
| | - Andrew M Freeman
- Department of Medicine, Division of Cardiology, National Jewish Health, Denver, Colo
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5
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Aggarwal M, Grady A, Desai D, Hartog K, Correa L, Ostfeld RJ, Freeman AM, McMacken M, Gianos E, Reddy K, Batiste C, Wenger C, Blankstein R, Williams K, Allen K, Seifried RM, Aspry K, Barnard ND. Successful Implementation of Healthful Nutrition Initiatives into Hospitals. Am J Med 2020; 133:19-25. [PMID: 31494109 DOI: 10.1016/j.amjmed.2019.08.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/14/2019] [Accepted: 08/28/2019] [Indexed: 02/05/2023]
Abstract
Poor dietary quality is a leading contributor to mortality in the United States, and to most cardiovascular risk factors. By providing education on lifestyle changes and, specifically, dietary changes, hospitals have the opportunity to use the patient experience as a "teachable moment." The food options provided to inpatients and outpatients can be a paradigm for patients to follow upon discharge from the hospital. There are hospitals in the United States that are showcasing novel ways to increase awareness of optimal dietary patterns and can serve as a model for hospitals nationwide.
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Affiliation(s)
- Monica Aggarwal
- Division of Cardiology, University of Florida, Gainesville, Florida.
| | - Ariel Grady
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Daya Desai
- University of Florida, Gainesville, Florida
| | | | - Lilian Correa
- Department of Medicine, NYC Health + Hospitals/Bellevue, New York
| | | | - Andrew M Freeman
- Division of Cardiology, Department of Medicine, National Jewish Health, Denver, Colo
| | | | - Eugenia Gianos
- Division of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Koushik Reddy
- Division of Cardiology, James A. Haley VA Medical Center, Tampa, Fla
| | - Columbus Batiste
- Division of Cardiology, Kaiser Permanente Riverside Medical Center, Riverside, Calif
| | - Christopher Wenger
- Division of Preventative Cardiology, Lancaster General Hospital/Penn Medicine, Lancaster, Pa
| | - Ron Blankstein
- Division of Cardiology, Brigham and Women's Hospital, Boston, Mass
| | - Kim Williams
- Division of Cardiology, Rush University Medical Center, Chicago, Ill
| | - Kathleen Allen
- Geisel School of Medicine, Dartmouth Medical School, Hanover, NH
| | - Rebecca M Seifried
- Division of Cardiology, Walter Reed National Military Medical Center, Bethesda, Md
| | - Karen Aspry
- Brown University, Warren Alperty Medical School, Providence, RI
| | - Neal D Barnard
- George Washington University School of Medicine, and Physicians Committee for Responsible Medicine, Washington, DC
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6
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Elkoustaf R, Patel M, Rao R, Batiste C, Quon S, Newman D, Shi J. P5497The gender paradox in non-ST-segment elevation acute coronary syndrome: an outdated paradigm or a persistent reality-an analysis of contemporary practice from an integrate health care system. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Although sex related differences in Non-ST-Segment elevation (NSTEMI) acute coronary syndrome (ACS) have been well delineated in the past, there is a paucity of data from contemporary practice on the evolutions of this paradox and its clinical practice implications.
Purpose
We hypothesized that in the era of guideline driven contemporary practice, and in the setting of an integrated heath care model, gender related differences in care and outcomes would be marginal at best if no altogether absent.
Methods
We utilized data from an integrated health care system to identify 4099 patients with NSTEMI-ACS (1531 women; 2561 men). The patients were stratified by gender and a comparative analysis was performed on guideline directed medical therapy, revascularization strategy and major adverse cardiac events between the two groups.
Results
There were significant difference in pharmacologic treatment, catheter based interventions and surgical revascularizations strategies. Underutilization of guideline directed medical therapy was demonstrated in women specifically vis a vis angiotensin converting enzyme inhibitor (ACE-I) (p=0.0014), statins (p=0.0001), and antiplatelet therapy: clopodigrel (p=0.0004), prasugrel (p=0.0012), and ticagrelor (p=0.03). Additionally, clear differences emerged in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) options despite similarities in high risk status at index presentation by well validated risk algorithms. Specifically, men were more likely to undergo PCI (p=0.021) and CABG (p<0.001) than women. Finally, women had a greater incidence of bleeding complications (p=0.0003) and stroke (p=0,038).
Conclusions
There were treatment disparities in pharmacologic interventions, catheter based interventions, surgical revascularization access and clinical outcomes among patients with NSTEMI-ACS. The persistence of this gender paradox in contemporary practice and despite increasing education and awareness should potentiate further public policy initiatves as well as reinforce the need for geneder specific guidelines
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Affiliation(s)
- R Elkoustaf
- Southern California Permanente Medical Group, Riverside, United States of America
| | - M Patel
- Southern California Permanente Medical Group, Riverside, United States of America
| | - R Rao
- Southern California Permanente Medical Group, Riverside, United States of America
| | - C Batiste
- Southern California Permanente Medical Group, Riverside, United States of America
| | - S Quon
- Southern California Permanente Medical Group, Riverside, United States of America
| | - D Newman
- Southern California Permanente Medical Group, Riverside, United States of America
| | - J Shi
- Southern California Permanente Medical Group, Riverside, United States of America
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Elkoustaf RA, Ismail M, Batiste C, Mercer A, Aldaas O, Newton D. DIET AND ISCHEMIC BURDEN: A COMPARATIVE ANALYSIS OF A PLANT BASED REGIMEN VERSUS A MEDITERRANEAN REGIMEN IN PATIENTS WITH CORONARY ARTERY DISEASE. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)33437-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Long lasting postural puncture headache secondary to an unintentional dural puncture (UDP) during epidural anaesthesia (EA) or following deliberate dural puncture for spinal anaesthesia, and neurological or neuroradiological examination, is becoming unusual. Placing the bevel of Tuohy needle parallel to the longitudinal axis of the dural cylinder when searching for epidural space, and in the later cases, widespread use of small diameter, atraumatic needles, have decreased both its incidence and severity. Furthermore, in the absence of any contraindication, patients suffering from such troubles are now quite systematically offered a curative epidural blood patch (EBP) whose effectiveness is documented. Authors report an original case of a fainthearted patient who underwent caesarean section under EA when she was 31-year-old, and whose disabling painful symptoms related to a UDP were successfully relieved by one EBP that she ended to accept more than seven years later. On the occasion of a short literature review, physiopathology and management are debated.
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Affiliation(s)
- L Raffin
- Clinique Les Martinets, 97, avenue Albert-1(er), 92500 Rueil-Malmaison, France.
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Abstract
This report describes a 25-year-old man with a pierced tongue in whom Streptococcus constellatus endocarditis of the aortic valve developed. Bacterial endocarditis in this patient was complicated by the development of a mycotic aneurysm of the right aortic sinus of Valsalva. Transthoracic and transesophageal echocardiographic studies were useful for the diagnosis of this rare lesion. Findings were confirmed at operation.
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Affiliation(s)
- Columbus Batiste
- Division of Cardiology and Cardiothoracic Surgery, Loma Linda University School of Medicine, Loma Linda, California 92354, USA
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