Category: Aortic Dissection News Page 2 of 11

Cocaine-induced Type-A Aortic Dissection Extending to the Common Iliac Arteries

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Abstract

Aortic dissection is a rare and fatal complication of cocaine-induced hypertension. The injury mechanism is through shear stress that penetrates the intimal vessel layer, allowing blood flow to separate intimal and medial layers. Due to its scarcity and the paucity of related literature, our knowledge of this condition is limited. We present a rare case of a cocaine-induced aortic dissection, which extended continuously from the aortic root to the common iliacs, along with a literature review of similar cases.

A 48-year-old male with recent cocaine use presented with left-sided chest-pain, which radiated to the back with nausea, diaphoresis, and shortness of breath. The patient was hypotensive. The initial radiographs and computed tomography were negative. The cardiac enzymes were elevated and the patient was admitted to rule out acute coronary syndrome. Next day echocardiogram and computed tomography revealed a Type-A aortic dissection continuously extending from the aortic root to the left common iliac artery. The patient was immediately transferred for surgery. Postoperatively, he developed acute kidney injury and shock liver. The patient status continued to deteriorate and he expired on postoperative day four.

This case demonstrates the importance of prompt and thorough diagnostic evaluation, despite subjective history and initially negative imaging that might point towards other conditions. Unlike the previous cases, our case failed to identify the positive history of cocaine until nearly 24 hours into the patient’s hospital course, suggesting a need for close monitoring in these patients and a possible need for repeat imaging.​​​​​​​

Kinking of an open stent graft after total arch replacement with the frozen elephant technique for acute Type A aortic dissection

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Interactive CardioVascular and Thoracic Surgery, ivx387,https://doi.org/10.1093/icvts/ivx387
Published:

 

10 January 2018

 

Article history
 Abstract
Recently, in Japan, the J Graft Open Stent Graft (JOSG) was commercialized for surgical repair of an aortic aneurysm and aortic dissection and the frozen elephant trunk technique was applied. Kinking of the JOSG is a rare adverse event that requires additional intervention. We experienced 2 patients who developed kinking of a JOSG after translocated total arch replacement with the frozen elephant trunk technique for acute Type A aortic dissection. Both patients had intermittent claudication with a decreased ankle–brachial pressure index after the operation. Computed tomography angiography showed kinking between the non-stent and stent parts of the JOSG. Therefore, we performed endovascular repair. A severely angulated arch preserved by a translocated technique may lead to kinking of a JOSG. This suggests that the removed non-stent part should be as short as possible to prevent kinking of the JOSG.

INTRODUCTION

The J Graft Open Stent Graft (JOSG) (Japan Lifeline Inc., Tokyo, Japan) (Fig. 1) was commercialized in 2014 in Japan [1] and is applied using the frozen elephant trunk (FET) technique for extensive aortic arch aneurysm and aortic dissection. In aortic dissection, the FET is used for closing the entry of the descending aorta, securing flow of the true lumen and decreasing the pressure of the false lumen, which may promote thrombosis of the false lumen. The E-vita OPEN PLUS (Jotec Inc., Hechingen, Germany) and Thoraflex Hybrid (VASCUTEK Ltd., Scotland, UK) have been used in Western countries with good results [23]. Similarly, although the JOSG has different characteristics compared with other open stent grafts, good early outcomes after total arch replacement (TAR) with the FET using the JOSG for acute Type A aortic dissection have been reported [4]. However, some adverse events are associated with this procedure, requiring additional interventions [1–4]. Kinking of the JOSG is rare [1]. We describe 2 patients who developed kinking of JOSGs after TAR with the FET for acute Type A aortic dissection.

Figure 1:

The J Graft Open Stent Graft. (A) Stent part. (B) Non-stent part.

CASE REPORT

Case 1 was a 44-year-old man, who was transferred to our hospital because of chest pain. Computed tomography (CT) angiography showed acute Type A aortic dissection that consisted of entry of the ascending aorta and large re-entry of the descending aorta with compression of the true lumen by a patent false lumen. Therefore, he underwent translocated TAR with the FET emergently. After TAR, transoesophageal echocardiography detected kinking of the JOSG. We then performed a remodelling root procedure because of aortic root rupture near the left coronary artery ostia and aorto-left femoral artery bypass to maintain blood flow of the lower body. After the operation, our patient developed intermittent claudication. CT angiography showed kinking between the non-stent and stent parts of the JOSG due to a severely angulated arch (Fig. 2A). This required additional endovascular repair. After endovascular repair, CT angiography showed an expanded lumen of the JOSG (Fig. 2B).

Figure 2:

(A and C) Computed tomography angiography after the operation in Cases 1 and 2, respectively. The black arrow shows kinking of the J Graft Open Stent Graft. (B and D) Computed tomography angiography after endovascular repair in Cases 1 and 2, respectively.

Case 2 was a 30-year-old man, who had annuloaortic ectasia and moderate aortic valve regurgitation with Marfan syndrome. CT angiography showed acute Type A aortic dissection from the aortic root to the thoraco-abdominal aorta with entry of the ascending aorta and a patent false lumen. Therefore, we performed a reimplantation root procedure and translocated TAR with the FET emergently. After the operation, he had decreased blood pressure in the lower body and intermittent claudication. CT angiography showed kinking between the non-stent and stent parts of the JOSG caused by a severely angulated arch (Fig. 2C). We then performed additional endovascular repair, which improved kinking of the JOSG (Fig. 2D).

DISCUSSION

Coarctation or kinking of an open stent graft after TAR with the FET is a rare adverse event. Uchida et al. [1] reported kinking between the non-stent and stent parts of the JOSG for a sharply bending aorta. We also experienced 2 patients who developed kinking of the JOSG between the non-stent and stent parts after TAR with the FET for acute Type A aortic dissection. A risk of kinking may be a severely angulated arch in acute aortic dissection, which is associated with a relatively young age. Moreover, translocated TAR may aggravate this adverse event due to preservation of the curve of the aortic arch, instead of achieving haemostasis. Uchida et al. [1] recommended that the stent part should sufficiently cover the aortic arch, and the non-stent part should be kept as short as possible to protect the stent graft from kinking. E-vita OPEN PLUS and Thoraflex may prevent kinking of open stent grafts in severely angulated arches because these open stent grafts have no non-stent parts between the distal anastomosis site and the stent [23]. However, the JOSG has an inner stent made of nitinol wire with a soft woven graft, which reduces injury to the intima. This is different from other commercialized open stent grafts, such as E-vita OPEN PLUS, which consists of an outer stent. The inner stent end boundary between the non-stent soft woven graft and the stent may easily lead to kinking by an angulated arch compared with other open stent grafts. Therefore, in translocated TAR with the FET for acute aortic dissection, the removed non-stent part of the JOSG should be as short as possible to prevent kinking of the JOSG.

ACKNOWLEDGEMENTS

We thank Ellen Knapp from Edanz Group (www.edanzediting.com/ac) for editing the draft of this article.

Conflict of interest: none declared.

REFERENCES

 
 

Low Rate of Bailout Emergency Surgery During TAVR, but Caution Still Needed

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TAVR is not PCI, say experts. While complications needing bailout are rare with TAVR, when they occur they tend to be deadly.

Low Rate of Bailout Emergency Surgery During TAVR, but Caution Still Needed

The need for emergent cardiac surgery resulting from complications during transcatheter aortic valve replacement is a “rare event” but “highly consequential” when it is required, according to a large analysis of patients treated at European centers.

Emergent surgery for complications such as left ventricle guidewire perforation, annular rupture, valve embolization/migration, and aortic dissection was required in just 0.76% of TAVR-treated patients. Of these, more than one-third died within 72 hours and 46% died in-hospital.

“Although half of the patients with such complications proceeding to [emergent cardiac surgery] were salvaged acutely, mid-term outcomes were bleak,” Holger Eggebrecht, MD (Cardiovascular Center Bethanien, Frankfurt, Germany), and colleagues report in their study published online recently in the European Heart Journal. Prevention of complications needing emergent surgery remains the most important strategy for improving clinical outcomes of TAVR patients, they add.

Speaking with TCTMD, Tamim Nazif, MD (Columbia University Medical Center, New York, NY), said the study is a reminder that while TAVR is a less invasive procedure than surgery and is increasingly performed via a minimalist approach to expedite recovery and discharge, it does carry risk. “People tend to lose sight of that with the evolution in the field, but this is a sobering reminder that it’s a major cardiac procedure that comes with some degree of risk,” he commented.

That said, Nazif also found the results reassuring, particularly since they are in line with what has been observed in randomized clinical trials, such as PARTNER 2Aand the SAPIEN 3 registry. “It’s comforting that the real-world experience seems to be mimicking the trial experience,” he said.

Rodrigo Bagur, MD, PhD (Western University, London, Canada), who also was not involved in the study, pointed out that while the overall rate of emergency cardiac surgery is “quite low,” an additional 60 patients were considered for emergency surgery but did not undergo any procedure. The outcome of these patients is unknown, but “likely may have been fatal,” said Bagur.  

“The bottom line is that even though TAVI teams and operators became more and more proficient in different aspects of the procedure, there are still procedural-related complications that can occur and perhaps might not be absolutely predictable and/or avoidable,” he said.

Large Registry of European Centers

The new analysis from the European Registry on Emergent Cardiac Surgery During TAVI (EuRECS-TAVI) is based on 27,760 patients undergoing transfemoral interventions at 79 centers between 2013 and 2016. The mean age of TAVR patients was 82.4 years, and the mean logistic EuroSCORE was 17.1% (mean STS risk score was 5.8%). Less than one-quarter of patients were considered to be at high risk for surgery.

In total, 212 patients required emergency surgery for complications, the most frequent being left ventricular guidewire perforation (28.3%) and annular rupture (21.2%). More than 90% of the complications manifested acutely during the TAVR procedure, report investigators. Cardiac surgery was performed most frequently on the TAVR table in a hybrid catheterization lab (61.1%), while the remainder were transferred to the operating room.

Overall, 24.2% of those requiring emergency surgery died the day of the operation and 34.6% died within 72 hours. The in-hospital and 1-year mortality rate was 46.0% and 78.2%, respectively. In-hospital mortality was highest for patients needing surgery for annular rupture (62.2%), coronary obstruction (54.5%), aortic dissection (52.0%), and left ventricle guidewire perforation (50.8%).

Bagur pointed out that the rate of emergency surgery declined over time, which might be related to more systematic use of preprocedural CT planning. This allows physicians to select an appropriate valve type and choose how aggressive to be with pre- and postdilatation. He said the rate of left ventricle perforations seems high and deserves attention to reduce the risk, such as being more careful in shaping the wire or using preshaped guidewires.

The EuRECS data showed no significant difference between low- and high-volume hospitals with respect to the incidence of emergency surgery during TAVR and in-hospital mortality following the operation. Nazif said he was surprised by those findings, noting that a previous analysis of the Society of Thoracic Surgeons/American College of Cardiology TVT Registry did show that higher-volume centers had better clinical outcomes than low-volume institutions, including lower in-hospital mortality.

Is Surgical Backup Necessary? Yes, Say Experts

In an editorial, Craig Smith, MD (Columbia University Medical Center), writes that these latest results raise the question of whether TAVR should be restricted to centers that have on-site cardiac surgery. For Smith, a cardiac surgeon, it is “grossly obvious” that only centers with surgical backup perform TAVR, but he acknowledges that restricting the procedure to such centers is subject to intense debate.

“Opponents of restriction rely on two primary arguments—access and an analogy to PCI. The problem with ‘access’ is that it can have many different meanings,” writes Smith. “It becomes synonymous with ‘convenience’ when argued to be a patient’s ‘right’ to a TAVI program in every local hospital. The results from EuRECS suggest that patients under that scenario would be acquiring, along with convenience, access to unjustifiable risk.”

In the United States, the Centers for Medicare & Medicaid Services (CMS) has placed conditions on reimbursement, stating TAVR should take place in a facility using a heart team approach, which includes interventionalists and surgeons experienced in both procedures. CMS also requires that TAVR be performed at a hospital with on-site surgical backup. In Europe, there are centers where TAVR is performed without the surgical safety net.

For Nazif, the EuRECS analysis reinforces the need for a surgical presence at TAVR centers, particularly as physicians move into treating intermediate- and low-risk patients where a preventable mortality risk is not acceptable.

To TCTMD, Bagur pointed out that TAVR requires a team approach. Even if transfemoral TAVR is performed by interventional cardiologists, “it is important to rely on the rapid availability of our cardiac surgeons that were part of the clinical decision-making process.” He noted that performing TAVR in centers without surgical backup seems quite courageous but may result in some centers, including low-volume centers and/or those with insufficient training, “being unable to properly handle critical complications, such as saving 40% to 50% of lives as shown in the paper.”

In his editorial, Smith stresses that TAVR is not PCI, a procedure that has been shown to be acceptably safe in centers without surgical backup. Although the frequency of emergent surgery during PCI is in the range of 0.2% to 0.6%, complications are less lethal than in TAVR, where structural heart device complications are so challenging, writes Smith.

Nazif agreed. “These are very severe complications that carry very severe mortality rates,” he said. “We need to take TAVI seriously—it’s not the same as PCI. It should be done at experienced centers with surgical backup.”

Sources
  • Eggebrecht H, Vaquerizo B, Moris C, et al. Incidence and outcomes of emergent cardiac surgery during transfemoral transcatheter aortic valve implantation (TAVI): insights from the European Registry on Emergent Cardiac Surgery during TAVI (EuRECS-TAVI). Eur Heart J. 2017;Epub ahead of print.
  • Smith CR. Emergent cardiac surgery following TAVI: implications for the future. Eur Heart J. 2018;Epub ahead of print.
Disclosures
  • Eggebrecht, Smith, Nazif, and Bagur report having no relevant conflicts of interest.

How Marfan Syndrome Can Impact Your Heart Health

5 common questions answered by a heart surgeon

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[dropcap]A[/dropcap]bout 90 percent of people with Marfan syndrome will develop changes in their heart and blood vessels.

If you have Marfan syndrome, you have abnormal connective tissue that can cause your blood vessel walls to weaken and stretch. This damage often affects the aorta, the main artery that carries blood from your heart to the rest of your body.

When the walls of your aorta stretch, you have a higher risk of:

  • Aortic aneurysm (bulging)
  • Dissection (tearing)
  • Rupture (bursting)

These can lead to a life-threatening medical emergency.

In this Q&A, Lars Svensson, MD, PhD, Chairman of Cleveland Clinic’s Sydell and Arnold Miller Family Heart & Vascular Institute, answers five of the most common questions he hears from patients with Marfan syndrome.

Q.: When does an aortic aneurysm require surgery?

A.: The larger the aneurysm, the higher the risk of dissection or rupture — and need for emergency surgery. Preventive, repair surgery is an elective, non-emergency procedure that has much better outcomes. Futhermore, long term survival is then similar to age and gender matched survival for the United States.

For the way Cleveland Clinic performs the modified reimplantation operation, now exceeding 700 patients, for elective surgery a mortality risk of less than 0.5 percent can be expected and a 95 percent or better likelihood of the repair working beyond 10 years after surgery.

Typically, we recommend repair surgery when aneurysms become 5.5 cm or larger. However, we may recommend it sooner if you have:

  • Marfan syndrome
  • Loeys-Dietz syndrome
  • Shorter, smaller stature
  • Family history of aortic dissection
  • An aneurysm that is growing quickly (5 mm or more per year)

Q.: Can I stop my aortic aneurysm from growing?

A.: Aneurysms can grow quickly or not at all, depending on the underlying disease. That’s why we monitor them with regular echocardiograms, or cardiac MRI or CT scans, if needed. Blood pressure control is important.

For patients with Marfan syndrome, the best ways to try to limit the growth of an aortic aneurysm is to:

  • Keep blood pressure below 130/80 mm Hg. Often, we will prescribe beta blockers, ACE inhibitors or other medications to help
  • Maintain healthy cholesterol levels
  • Keep resting heart rate below 70 beats per minute
  • Eat a plant-based diet
  • Exercise moderately
  • Avoid smoking

Q.: What does an aortic aneurysm feel like? How do I know if I have one or if it’s getting worse?

A.: Most of the time, you can’t feel an aneurysm. The only way to detect one or see if it’s changing is through imaging scans.

However, if an aneurysm is quite large, you may have:

  • Pain in the jaw, neck, upper back or chest
  • Coughing, hoarseness or difficulty breathing
  • Pain in the lower back, abdomen or groin not relieved by body movement or taking pain medication

If your aorta has started to tear, you may feel severe pain in your chest or back or both. Some people also report pain in the abdomen or stroke symptoms, including sudden weakness, numbness or loss of balance.

Call 911 if you have any of these symptoms.

Q.: Should I be careful about exercising if I have an aortic aneurysm?

A.: In general, people with aortic aneurysms can still do aerobic exercise, while carefully monitoring their heart rate. Sometimes a stress test will help us assess the heart and determine appropriate heart rate limits.

We typically advise patients to avoid heavy isometric exercise and to not lift more than half of their body weight. Doing multiple repetitions with lighter weights is OK.

There are no limits on physical exercise or exertion after you’ve had (and recovered from) surgery to repair an aortic aneurysm. Cleveland Clinic has cared for professional athletes who’ve returned to active competition.

Q.: Should I be careful about doing other recreational activities if I have an aortic aneurysm?

A.: Flying in an airplane, sitting in a hot tub and jumping on a trampoline are typically safe for people who have an aortic aneurysm. There is no scientific evidence indicating otherwise.

Riding roller coasters or other thrill rides may be best to avoid, however. They can cause blood pressure to swing rapidly.

 

Tom Tolbert on life after heart surgery: New perspective, same old humor

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[dropcap]T[/dropcap]here’s a vine that needs trimming on Tom Tolbert’s roof. It’s an assignment he savors, tricky and satisfying as he saves himself a few bucks, but Tolbert’s roof-climbing days are over.

 

It’s just that Tolbert, 52, walks a fine line in his recovery from his surgery, a thoracic aortic dissection. The odds were heavily against him surviving the initial operation to repair a tear in body’s largest artery, and he required three subsequent procedures to ward off the complications.

There were times this fall when the former NBA player was unable to walk more than a few steps before retreating in exhaustion. “It’s all about my blood pressure now,” he said. “Maintain that at a proper level, they tell me. Be kind to the aorta.”


Tolbert was at home watching a Giants baseball game at around 9 p.m. on the evening of Aug. 29 when he suddenly felt pain in both of his temples.

“I’m thinking, what the hell is that?” he recalled. “Then both of my shoulder blades started hurting, and then my chest and throat were throbbing. I thought I was having a heart attack, so I got on the computer and Googled the symptoms. They weren’t associated with a heart attack, but I knew something was wrong.”

Shivering cold but drenched in sweat, he went upstairs to climb in bed with his wife, Lorrie, who had turned in early that night.

“I heard this faint voice…‘Sugar’… That’s what we call each other. ‘I don’t feel very good.’ Tom has an unbelievably high threshhold for pain, so I knew it was bad. We got down to Alameda Hospital in a hurry. They ran a series of tests, and when the doctor came in, he said, ‘It’s your aorta. You’re going to need surgery. Immediately. Tonight.’”

That ambulance ride said a great deal about Tolbert and his demeanor. He could be quite the boastful boor at this stage of his life, having been a high-profile star at the University of Arizona and a seven-year veteran of the NBA, including three memorable seasons as a 6-foot-7 power forward under Warriors coach Don Nelson in the early 1990s.

He’s a rare and endearing brand of talk-show host, combining the authoritative voice of an ex-athlete with a fan’s ceaseless devotion. But there isn’t a trace of cockiness or self-obsession in his manner, on or off the air — and his first reaction, to just about anything, is humor.

“So we’re buzzing down to Stanford, and I noticed that they’d handcuffed my gurney to the side of the ambulance. So I had ‘em take a picture with me giving the thumbs-up: ‘They finally got me,’” he laughed. When Tolbert got to the surgery room, being introduced to all sorts of people, he borrowed a line from the movie “Animal House” to greet them all: “Tom Tolbert, rush chairman, damn glad to meet you.”

“I just think there are only so many things you can control in your life,” Tolbert said. “There’s nothing I can do about surgery, so I might as well be as loose as I can, have some fun with it. I’ve always had that ability when something’s out of my hands. Here we’ve got this team of surgeons, and they’re the best. I just kept thinking, ‘They’re gonna get this done.’”

Afterward, Tolbert got the grim news that “there were a number of ways it could have gone worse than it did. My doctor said if the dissection had gone upward, toward the heart, instead of downward, I would have died. And he said, ‘If I didn’t already have you opened up when the dissection happened, you’re probably done.’”

About a week after returning home, Tolbert taped an upbeat message for his KNBR listeners to hear. He was back in the studio on Oct. 9, and for the last two months, he’s been able to drive himself to his workplace of 21 years. He felt about the same during those first few shows, but he didn’t look it, having lost nearly 40 pounds (down to 255) through the ordeal.

“That’s the first thing that jumped out, like, whoa!” Lund said, recalling the sight of a slimmed-down Tolbert. “A few things were different. We had to make sure he had a convenient parking place, and sometimes he has to get up during the show to keep the blood circulating. But basically, it’s like he never left. We’ve quit asking about his energy, because it’s always high. That great sense of humor never left him.

Warriors coach Steve Kerr, a longtime friend dating back to their playing days at Arizona, recalled their first conversation after the surgery: “He said, ‘Yeah, I was looking for ways to lose weight. I thought about diet. I thought about exercise. Then I just settled on heart surgery. It’s worked out really well.’ Typical Tom. Incredible outlook. Most of his life is based on sports and humor and people and friends. He’s just a beautiful human being.”


Lorrie recognized that great quality in her husband, but she was deeply shaken by his post-surgical condition. “From the perspective of seeing Tom as this big, solid, brawny guy, it was pretty dramatic and emotional for me,” she said, right about the time Tom pulled up his shirt to reveal a foot-long, vertical scar running down his abdomen. “I’m still feeling the effects of what happened. It’s incredibly stressful. You don’t feel it for the first few weeks, and then your world kind of falls apart a little bit.”

Nobody was quite prepared for the debilitating condition of his legs — not even his doctors, because the chance of surviving his initial operation was so low. “They’ve had to get creative,” said Lorrie. “After three more operations (all at Stanford), you wonder if he’ll ever be able to walk normally again.”

Tolbert recalled “just trying to walk around the kitchen, into the dining room and do a full circle, maybe four times. Then I had to rest for three or four minutes and do it again, just to keep my muscles intact.” After the last procedure — his fourth in seven weeks — he actually felt worse, he said. “I could barely make it from the street to the house. My quads were killing me; I just felt done.”

When he woke the following morning, though, there was only a bit of pain. He was able to walk around the kitchen 10 times, he said. “It was like a miracle to me. It was such a breakthrough, I started crying.

“And I remember needing to get out and walk outside. It was right around the time of the Santa Rosa fires, so the air was filled with soot and smoke, but I got out there, walked about 100 yards down the street and was so happy. That’s all I wanted.”

Tolbert said he walks up to five miles at a stretch now, four or five times a week, and hopes he might return to playing golf at some point.

To maintain the proper level of blood flow, doctors inserted several stents in his coronary arteries to keep them open; they are likely to remain in place for the rest of his life. Because his condition can only be monitored, not healed, and the high risk of aneurysm, his life centers around a proper diet and maintaining low blood pressure.

As such, Tolbert has been forced to abandon a life of heavy weightlifting, Friday night pizza dinners and the joy of consuming whatever he wanted.

“Sodium is the big thing I have to avoid, and I’m at the store reading every label now,” he said. “And beer is OK, thank God. In fact, my doctor told me, ‘Make sure you have your 7-10 beers a week, it’s actually good for you.’ And I was like, ‘Can I have seven this Saturday?’ Uh, no, that’s not how it works.”


When an inevitable question arose — what brought this on? — Tolbert didn’t need much thought.

“Basically, I’ve turned into my dad,” he said.

According to Lorrie, 78-year-old Tom Tolbert Sr. has had 22 procedures over the years, all related to the aorta.

“You think Tom’s scar is nasty; his dad’s runs completely top to bottom. So we’re in the middle of genetic testing right now, to find out for sure if all our kids need to be monitored,” she said. “We learned there’s a mutated genetic gene that causes dissection, and we’re trying to find out everything we can.”

As Tolbert sat talking about his future, he dropped his carefree facade.

“I’m so grateful to have my kids, my friends and my wife taking care of every little thing,” he said. “I really believe it helps the healing process when you have those types of vibes coursing through your body. I mean, I don’t get through any of this without Lorrie. She’s the best. I just love her to death.”

Lorrie, seated nearby, walked over and planted a big kiss on her man.

Bruce Jenkins is a San Francisco Chronicle columnist. Email: bjenkins@sfchronicle.com Twitter: @Bruce_Jenkins1

Bruce Jenkins

Bruce Jenkins

Sports Columnist

Viewpoint: Ask Patients Flat-Out Do You Have a Problem with Pain Meds?

article source:

Roberts, Martha ACNP, PNP

doi: 10.1097/01.EEM.0000529885.73957.75
Viewpoint
 
 
pain medication

pain medication

[dropcap]Y[/dropcap]our next patient is a 32-year-old woman complaining of a headache. You check her vitals: a heart rate of 101 bpm, blood pressure of 150/90 mm Hg, sat of 100%, respirations of 22 bpm, and a 10/10 on the pain scale. You talk to her about her complaint of headache. She says she is allergic to Tylenol.

The patient is calm, healthy-looking, and in no distress. You do your usual head-to-toe review, and ask your typical history and physical questions. Her neurological exam is negative. She is positive for a wide range of complaints—body aches, crampy back pain, runny nose, slight abdominal pain, maybe some diarrhea, and of course, the headache. You spend minimal time on the other systems, and inquire about her main complaint. Because this patient has a plethora of issues and is of child-bearing age, you check her CBC, BMP, ECG, flu, UA, and hCG. You know they are going to come back negative. You consider a D-dimer because she is on birth control and might be PERC-positive, but you’re not convinced this is PE-related.

What if we start the conversation differently? What if we did an HPI with specific questions? She has been to the ED before, and doesn’t have a primary care physician. Nothing stands out as an emergency. You wonder if a workup is necessary, but don’t want to miss any zebras. A few clues suggest this could be something nefarious, but the opioid epidemic should tell us otherwise.

The bottom line is patients want pain medications. We have to figure out if a patient is drug-seeking or has a valid complaint. The problem is we cannot predict what she has based on a limited history and physical. The answer to this case lies in our bedside manner, approach, and honesty. Opioid abuse, misuse, withdrawal, and addiction are not diagnoses of exclusion; none of us wants all those tests done.

ED visits and overdose deaths involving opioid analgesics and benzodiazepines increased from 0.6 to 1.7 per 100,000 between 2004 and 2011. (Am J Prev Med 2015;49[4]:493.) The number of deaths per year attributed to prescription opioid medications reached 16,651 in 2010. (MMWR 2013;62[12]:234; http://bit.ly/2yM9QfS.)

We don’t ignore the one or two percent risk of certain diagnoses like PE, MI, and aortic dissection, so why ignore the signs of drug-seeking? The abuse of and addiction to opioids is a serious global problem that affects the health, social, and economic welfare of all societies. (National Institutes of Health, 2014; http://bit.ly/2yPhFUg.) Just like we would not forget to ask about smoking or cholesterol levels in a patient with chest pain, we cannot forget to ask about pain medication use.

It is estimated that between 26.4 and 36 million people abuse opioids worldwide. (United Nations Office on Drugs and Crime, 2012; http://bit.ly/2yQcYJU.) An estimated 2.1 million Americans suffered from substance abuse disorders related to prescription opioid pain relievers in 2012, and 467,000 people are addicted to heroin. (Substance Abuse and Mental Health Services Administration, 2013; http://bit.ly/2yRKaAw.) Surely, the smaller percentage of those with PE, MI, or dissection is outweighed by a diagnosis of opioid abuse or withdrawal.

A study in the Western Journal of Emergency Medicine looked at 178 patients from the case management program who made 2,486 visits in one year. (2012;13[5]:416.) Headache accounted for 21.7 percent and back pain 20.8 percent, while requesting a refill took up seven percent, lost or stolen medication 0.6 percent, 10/10 pain 29.1 percent, greater than 10/10 pain 1.8 percent, and out of medication 9.5 percent. Not every headache is going to be a stroke.

Just as we take measures to rule out PE, dissection, and MI by risk-stratifying patients, we should consider an individual’s risk for abuse before prescribing opioids. (Ann Emerg Med 2016;68[4]:S81.) We are behind the times if we do not risk-stratify patients for potential abuse or misuse. Narcotics-seeking is often hidden among the initial investigation. It may even get lost in a triage provider’s initial questions and three to four hours of unnecessary tests. Neither the provider nor the patient really wants to talk about narcotic abuse, but we should be asking our patients flat-out: Do you have a problem with narcotic pain medication use?

Addiction has a strong, visceral hold on our patients, and we are ignoring the easy stuff. Questioning our patients directly about it should not be a game. When all the information is gathered in the initial interview without bias or judgment, patients are more likely to get the treatment they need. This may stop us all from doing unnecessary workups and costly imaging.

Next time we interview a patient, we should ask if he has tried anything for pain and list multiple medications: acetaminophen, ibuprofen, tramadol, morphine, or methadone. Patients may not be upfront about these medications if they have true addiction issues. They are fearful we will not prescribe pain medications or treat their acute pain. When we set the standard of care in the beginning, however, we can avoid drama and overtesting.

We should ask every patient of every age and walk of life about his personal experience with pain and then consider how to address it. This starts with being upfront in a nonjudgmental way and using a team approach to their care. It may prevent thousands of deaths and save hospitals millions of dollars. It will also get patients the help they actually need. The nature of their complaint doesn’t even matter, but our practices can change because of it.

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Year in Review: Physicians Pick the Biggest News of 2017, in Interventional Cardiology and Beyond

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TCTMD journalists asked a range of experts about what developments rocked the field this year—or at least made it tremble. Here’s what they had to say.

[dropcap]I[/dropcap]n the last few weeks of 2017, the entire TCTMD news team reached out to a range of cardiologists around the world to ask what they see as the biggest studies, the most auspicious advances, or the most conspicuous flops of the year gone by. Here’s what they had to say.

Coronary Artery Disease

No surprise: several of the physicians we spoke with mentioned the ORBITA trial. “Interesting and provocative,” Allen Jeremias, MD (St. Francis Hospital, Roslyn, NY), called the trial results, which have met with robust debate since they were reported at TCT 2017. Jeremias said he would be interested in seeing an analysis of the roughly three-quarters of patients who had abnormal physiology at baseline and who might derive a benefit from PCI.

Allen Jeremias
Allen Jeremias, MD

ORBITA was on the list for Andrew Foy, MD (Penn State Hershey Medical Center, PA), as well. “I would have been one of those people that would have hypothesized that a lot of the subjective benefit of PCI would not be present in a sham-controlled trial, but it was great that this trial was able to be done. It really shows that interventions aimed at improving subjective endpoints need to be subject to rigorous study. It would be nice if we would do these studies before the widespread adoption of the service as opposed to after the fact.”

Foy said ORBITA should be a game-changer, but doesn’t think it will be, unfortunately. “At least it gets people thinking though, that when it comes to these things, maybe we should be doing more sham-controlled trials and that it’s not unethical,” he said. “In fact, it’s really helpful.”

While ORBITA seemed to steal the show in the last 2 months of the year, Jeremias argued that the DEFINE-FLAIR and iFR-SWEDEHEART trials, showing that instantaneous wave-free ratio (iFR) was noninferior to fractional flow reserve (FFR) for guiding revascularization decisions in intermediate lesions, were arguably the bigger story in CAD this year. Jeremias said he expects to see a lot of interesting subanalyses in the coming year, but believes the trials have already had an impact.

Ik-Kyung Jang, MD
Ik-Kyung Jang, MD, PhD

“I’ve been using both for quite some time, but I’ve spoken to many people and they basically completely abandoned FFR and now switched over to iFR, which I think might be a little bit of a strong statement,” he said. “There’s a role for both but in terms of usability, iFR certainly is more user-friendly. It’s quicker, with less side effects because you don’t have to give adenosine. So it’s a more appealing concept for sure.”

The two iFR/FFR trials also got the nod from Ik-Kyung Jang, MD, PhD (Massachusetts General Hospital, Boston, MA), who told TCTMD that at his center, FFR has been almost completely replaced by iFR. “When those two large trials were done independently and showed almost superimposable data, it was very convincing,” Jang said.

Jeremias said important developments also occurred in the areas of complete revascularization for patients with acute MI complicated by cardiogenic shock (CULPRIT-SHOCK), left main PCI, and bioresorbable scaffolds. The latter weathered its share of alarmist headlines in 2017 and was ultimately taken off the market.

“It’s a disappointment,” Jang said, “but I don’t think it’s dead. I think the better second-generation versions will come shortly.”

Joanna Wykrzykowska, MD (Academic Medical Center, Amsterdam, the Netherlands), said the disappointing results of bioresorbable scaffolds shifted focus back to metallic DES. “When everybody realized . . . that the bioresorbable scaffolds were not ready for prime time and were not going to bring down the risk of stent thrombosis to zero as promised, I think we all started rethinking metallic drug-eluting stents.

Joanna Wykrzykowska, MD
Joanna Wykrzykowska, MD

“The question in everybody’s mind,” she said, “is whether or not there are DES platforms where you can afford to reduce DAPT—to decrease the bleeding risk when somebody has to operate or because the patient has a high risk of bleeding—without the additional risk of stent thrombosis. This is the thinking behind a lot of the ongoing trials.”

Wykrzykowska cited several DAPT de-escalation trials as the “big news” of 2017, including CHANGE DAPT and PRAGUE-18.

“We see in clinical practice that people who take ticagrelor have a lot of little nuisance bleeds,” said Wykrzykowska. “Even if they have STEMI or NSTEMI and indications for 1-year of treatment with aspirin and ticagrelor, these studies have shown that it’s okay after a month to switch down to aspirin and Plavix.”

In addition, several ongoing trials will provide important answers with regard to DAPT duration and stent technology, said Wykrzykowska.
 


Clinical Cardiology and Prevention

Michael Miller, MD
Michael Miller, MD

Secondary prevention of CVD saw some of the biggest trials in 2017, including FOURIER and CANTOS. “These results were more robust compared with 2015’s IMPROVE-IT trial that used the cholesterol absorption inhibitor ezetimibe (Zetia, Merck/Schering-Plough),” Michael Miller, MD (University of Maryland Medical School, Baltimore, MD), told TCTMD.

With regard to FOURIER, Miller said one aspect of the study that particularly impressed him was the continued benefit of evolocumab (Repatha; Amgen) when on-treatment LDL cholesterol levels were reduced to as low as 10 mg/dL. At these extremely low levels, there was no signal of risk observed, he noted. Alternatively, CANTOS demonstrated support for the inflammatory hypothesis and represented a new means of treatment outside of lowering LDL cholesterol.  

Foy, on the other hand, wasn’t as impressed with FOURIER. In fact, what struck him the most was the hubristic thought that adding evolocumab to optimized high-dose statin therapy could abolish the residual risk of cardiovascular events in a secondary-prevention population.

“Sometimes people joke with me that I’m a medical Luddite,” said Foy. “It’s not that I’m against progress, because I’m not, but this study is interesting because evolocumab, more or less, wipes out LDL cholesterol, or at least to very low levels in patients with atherosclerotic cardiovascular disease. Even though the trial was positive, what this shows is that we didn’t do very much.”

Andrew Foy, MD
Andrew Foy, MD

Foy said that even though LDL cholesterol levels were reduced to a median of 30 mg/dL in the trial, more than more than one in 10 patients in both groups experienced the primary efficacy endpoint.

“As a society, do we want to continue to invest heavily in treatment of disease once it already occurs?” asked Foy. “As this trial shows to some extent, we may not have much further to go. . . . Should we declare victory from a medical standpoint and start thinking about how to invest as a society in disease prevention, which gets us away from the doctor’s office and puts resources back into the community?”

While there was a lot of exuberance over FOURIER, investment in primary prevention, with walkable cities and cycling infrastructure, for example, would likely go a lot further than spending billions of dollars for an additional therapy in patients with cardiovascular disease, suggested Foy.

To TCTMD, Khurram Nasir, MD (Baptist Health South Florida, Miami), also cited the FOURIER trial, and like Foy argued that hard decisions need to be made about how much payers are willing to spend for an expensive medical therapy that yields solidly effective, but not miraculous, gains. “The benefit will seem substantial to some and modest to others,” said Nasir. “However, it reignited the debate on issues related to its pricing, cost, and value.”

The American Heart Association (AHA), the American College of Cardiology (ACC), and other societies can play leadership roles to resolve cost-related issues, he added. “Moving forward, rather than debate whether a PCSK9 inhibitor is or is not affordable, we need a conversation about whether it represents value for money,” said Nasir.

Khurram Nasir, MD
Khurram Nasir, MD

Several experts also pointed to the importance of the new hypertension guidelines from the AHA, ACC, and nine other partnering organizations that redefined hypertension as starting at a blood pressure of 130/80 mm Hg.

“The idea that we should be more aggressive about treating hypertension would be a big change in terms of getting a lot more patients on therapy,” Anne Curtis, MD (University at Buffalo, NY), told TCTMD.

She said she’d still be wary of aiming for aggressively low blood pressure goals in older patients, and wouldn’t, for example, try to get an 85-year-old’s readings down to 120/80 mm Hg. “The reason I say that is that a lot of times they have pretty stiff vessels and once you start trying to get too aggressive in lowering the blood pressure you can have problems with orthostatic hypotension or getting them dizzy.”

Stephen Little, MD (DeBakey Heart & Vascular Center, Houston, TX), also told TCTMD that he was happy to see the renewed antisodium message that came along with the revised guidelines because it “really sort of doubles down” on what physicians in the past have advocated.

“Every month or so we hear about new pharmaceuticals to [lower blood pressure], but it’s nice to see that people have gone back to the basics,” Little said. “It’s not particularly sexy, but in terms of clinical utility, it’s easy . . . not to burden patients with insurance or economic challenges with new therapies” and instead simply place them on a low-salt diet.
 


Arrhythmias

Curtis told TCTMD that the “coolest thing” this year in the realm of heart rhythm is a small study looking at noninvasive cardiac radiation for ablation of ventricular tachycardia. Though the study included only five patients who had failed other treatments, the approach provided “amazingly good results” by reducing episodes of ventricular tachycardia by 99.9%, Curtis said. “It potentially has a huge amount of promise—it’s going to require a lot more work and they’re doing prospective trials on it—but . . . if you could stop having to use catheters to push around the heart to figure out where to fix these things, it would just be a revolution in the management of these arrhythmias.”

Anne Curtis, MD
Anne Curtis, MD

The CASTLE-AF trial was another important development in electrophysiology, said Curtis. The trial randomized patients with heart failure and A-fib to either conventional drug treatment or catheter ablation. The primary endpoint of all-cause death or unplanned hospitalization for worsening heart failure strongly favored the ablation arm.

“There seems to be increasing evidence that when patients have A-fib and heart failure, if you can fix the A-fib, you can improve outcomes,” Curtis said, adding that the trial could have an impact on practice by making clinicians choose ablation earlier in that patient subset.

And finally, Curtis pointed to studies of His-bundle pacing as a major development. With permanent pacemakers, the lead typically goes in the right ventricle, requiring the impulse to travel through myocardium. His-bundle pacing, however, uses a very small lead placed on the septum to recruit the His-Purkinje system to pace the ventricles. That approach has yielded success rates of 85% to 90%, although information on longer-term outcomes is still needed, Curtis said.


Structural Heart Disease

Ted Feldman, MD (NorthShore University HealthSystem, Evanston, IL), said the single biggest thing to move the dial in 2017 is the New England Journal of Medicine’s decision to publish, in a single issue, three randomized trials supporting PFO closure for stroke prevention. “After more than a decade of struggling with trying to convince the noninvasive world that PFO closure prevents recurrent cryptogenic stroke, there’s now no ambiguity. The three trials, RESPECTCLOSE, and REDUCE, represent significant advances for the field, and most importantly those advances will have a positive impact on patients,” he said.

Mayra Guerrero, MD
Mayra Guerrero, MD

Mayra Guerrero, MD (NorthShore University HealthSystem), similarly placed PFO closure among the top news. “It really got our attention, but it did not surprise me,” she said. “Many of us knew that this would be positive and would just take time.”

Five-year findings from PREVAIL and PROTECT AF on the Watchman LAA closure device (Boston Scientific) also were a “highlight,” Guerrero observed.

Lars G. Svensson, MD, PhD (Cleveland Clinic, OH), told TCTMD that, for his center, the “most striking thing” is performing their first percutaneous tricuspid valve replacement. “We’ve done a number of patients now under compassionate use, and we’re now working with the [US Food and Drug Administration (FDA)] on a feasibility trial,” he said, adding, “That’s the big one for us.”

Moreover, “of course there’s a tremendous number of various devices that have popped up this last year both for the mitral valve and the tricuspid valve,” Svensson noted. “That’s a very exciting area of growth with transcatheter devices over time.”

An incremental advance that continued to be felt this year, Feldman agreed, is the growing momentum of transcatheter mitral valve replacement (TMVR). “We have seen and continue to see small strides being made by a variety of technologies to make the procedures more reproducible, and more often transseptal rather than transapical,” he said. Improvements in imaging have been critical here, he added. “With every endeavor we’ve ever had, imaging has led the way because you can’t go where you can’t see. We’re understanding how to look at those scans better and evaluate all the complexities of the mitral apparatus.”

Guerrero, too, cited early feasibility trials of TMVR, including her own MITRAL study, as well as results with the Tendyne and Intrepid valves. “Compared with other years, I think the common theme is that the findings of the recent trials [show better outcomes] than before with prior devices or prior attempts,” she said, echoing Feldman’s idea that “transseptal is a better way to go whenever possible” in mitral cases.

One milestone, Guerrero said, was the expanded FDA indications for Sapien 3 (Edwards Lifesciences), permitting its use in in mitral valve-in-valve procedures.

Lars Svensson, MD
Lars Svensson, MD, PhD

Another intriguing development, Svensson said, is the potential to combine multiple transcatheter devices in the same procedure. For example, the WATCH-TAVRmultinational study, just getting underway, is pairing the Watchman device with TAVR for patients who have both A-fib and aortic stenosis. Until recently, it was impossible to formally test these options, Svensson explained, because more than one investigational device cannot be combined in a single trial. Now, as more devices become FDA approved, it’s possible to study the effects of adding a newer contender to an existing therapy, he said.

Regarding the TAVR space, Guerrero said while there was no earth-shattering news, the accumulating trial data on lower-risk patients and initial forays into treating asymptomatic patients has kept the field’s interest. Specifically, the ongoing EARLY TAVR trial is changing clinicians’ perspectives, she commented. “We no longer have to wait for symptoms. We can take those patients with severe aortic stenosis and talk to them about early TAVR” with the hope of easier recovery and lower risk than surgery.
 


Cardiovascular Imaging

In the realm of cardiovascular imaging, Little told TCTMD that one of the most interesting topics explored in 2017 is the connection between cardiac amyloidosis and aortic stenosis as viewed on a new cardiac nuclear study called technetium pyrophosphate. “The gist of it is that there’s this phenotype of patients that we see with aortic stenosis that we send for TAVR and they have small ventricles, thick hearts, and a lot of diastolic dysfunction and it always gets ascribed to being elderly and having aortic stenosis,” he explained.

But studies this year have shown that amyloidosis is “very common” in those with aortic stenosis, who are often sent to undergo TAVR. At the moment, the data are merely “thought provoking,” Little said, but it’s likely going to lead to a more research given the lack of knowledge regarding the appropriateness of TAVR for these patients.

“One of the hardest things we do in the TAVR environment is deciding who’s not going to benefit from the therapy, but if somebody clearly has a burden of cardiac amyloid, then a TAVR is not going to fix that in any way,” he said. “Maybe there should be a discussion around futility and sort of potentially improving patient selection.”

 Kevin Harris, MD
 Kevin Harris, MD

Kevin Harris, MD (Minneapolis Heart Institute Foundation, MN), on the other hand, cited a very recent study that identified myocardial fibrosis in competitive male triathletes. In that study, the scarring detected by late gadolinium enhancement by cardiac magnetic resonance imaging was particularly pronounced in athletes who participated in long-distance events, such as Ironman triathlons.

Additionally, Harris pointed to a recent study that highlighted a subset of patients with hypertrophic cardiomyopathy (HCM) who have left ventricular apical aneurysms.

“It’s an interesting paper and gives us some good insights into a subset of patients with hypertrophic cardiomyopathy who are at a higher than expected risk [for arrhythmic sudden death],” said Harris. Additionally, HCM patients with left ventricular apical aneurysms were also at a higher risk of thromboembolic events.

Finally, Harris also cited a CT imaging study of patients with uncomplicated acute aortic dissection. In that study, imaging-based morphological features were combined into a prediction model to identify patients at high risk for late adverse events after an uncomplicated type B aortic dissection.
 


Endovascular Disease

Michael Jaff, MD
Michael Jaff, DO

“The biggest trial of the year by far in my opinion was the recently-published ATTRACT trial, which did not hit its primary endpoint,” said Michael R. Jaff, DO (Newton-Wellesley Hospital, Boston, MA). “This was a highly anticipated trial that had been ongoing for many years and it’s a highly controversial area of therapy.”

Jaff also pointed to 12-month results of the ILLUMENATEtrial. The low-dose paclitaxel-coated Stellarex balloon (Spectranetics) showed superior safety and efficacy compared with angioplasty alone in a multicenter trial of 300 PAD patients with claudication. Stellarex “became the third to the market as a result of this trial,” Jaff noted. “Overall, it was a very impressive time course from invention to FDA approval.”

Finally, Jaff said the finding that carotid stent fractures are not associated with adverse events, as reported in the ACT I trial, was another important advance in endovascular medicine. “Everybody kind of believed that if you have a stent fracture it results in a higher risk of stroke and death and need for repeat interventions. But it turned out that none of those were the case,” he remarked.
 


Heart Failure

Among the big news in heart failure this year, Paul Hauptman, MD (Saint Louis University School of Medicine, MO), pointed to the emergence of antidiabetic medications as therapies for reducing cardiovascular risk. In August, liraglutide (Victoza; Novo Nordisk), a glucagon-like peptide-1 receptor agonist, received an indication for reducing risks of MI, stroke, and cardiovascular death in adults with type 2 diabetes and established cardiovascular disease. That follows a similar decision for empagliflozin (Jardiance; Boehringer Ingelheim/Lilly), a sodium glucose cotransporter-2 inhibitor that received an indication at the end of 2016 for reducing the risk of cardiovascular death in adults with type 2 diabetes and established cardiovascular disease.

Paul Hauptman, MD
Paul Hauptman, MD

“It used to be thought of as maybe it’s just an issue of safety, but now it looks like . . . some of these drugs actually have favorable effects on the heart,” Hauptman told TCTMD, noting that there has been a resurgence of interest in diabetes in the heart failure community.

He pointed out that two new trials were launched in 2017 to look at use of empagliflozin in patients with heart failure and either preserved ejection fraction (EMPEROR-Preserved) or reduced ejection fraction (EMPEROR-Reduced); patients are not required to have diabetes. “It’s a first attempt now to extend findings from a main diabetes study to see whether or not—in this particular case—empagliflozin could actually be a heart failure drug in addition to being a diabetes drug,” Hauptman said.

Other major developments, he added, were the approval of the HeartMate 3 left ventricular assist device (LVAD), the expanded destination therapy indication for the HeartWare LVAD, promising early study results for a novel drug for symptomatic hypertrophic obstructive cardiomyopathy from MyoKardia and an interarterial shunt from Corvia Medical, and continued refinements of heart failure guidelines.
 


Policy and Practice

For Frederick Masoudi, MD (University of Colorado Anschutz Medical Campus, Aurora), the biggest news of the year affecting everyone from physicians to patients, and hospitals to insurance companies has been “the fight over the Affordable Care Act,” or ACA. “It seemed like the ACA had nine lives at least at one point, although I think that’s probably changed fairly substantially with the new tax legislation that’s been approved by both the House and the Senate that eliminates the mandates as part of the ACA.”

Looking back over 2017, he said there were several times when “things were looking pretty good for the ACA despite a lot of attempts to undermine enrollment.” However, the “poor public understanding” of the reasons why it is necessary to maintain both coverage for preexisting conditions as well as mandates and subsidies has contributed to the success of the tax legislation, Masoudi commented, adding, “Certainly what’s happened here at the end of the year is I think bad news for the ACA.”

Christopher Meduri, MD
Christopher Meduri, MD

To TCTMD, Christopher Meduri, MD (Piedmont Heart Institute, Atlanta, GA), said one of the overarching themes of 2017 has been the growth of early feasibility studies in the United States.

“If I look back to just a few years, it really seemed like every US interventionalist at any major meeting was watching the revolution in valvular heart disease from the sidelines,” he said. “We always dreamed of being up there doing some of these cases, or being involved with the new technologies. Fortunately, not just for investigators, but also for patients, the FDA has really developed a collaborative atmosphere between sponsors and the sites doing the early feasibility work. Now, more and more technologies are being tested in the US.” 

At TCT 2017, for example, there were presentations on several US-based, early feasibility valve-related trials, said Meduri. At his center, he has participated in two early feasibility studies, and at least three more valve-related technologies will be tested in the coming months. His institution has also been invited to participate in the FDA’s early feasibility trial network.

“I remember being a fellow and thinking, ‘You have to go to Europe to do anything.’ So I went to Europe for several months, trying to get my hands on some of these things I’d never get to do otherwise,” said Meduri. “Now, at some of the same places I trained at in Europe, there’s interest in coming over here [to the US] to watch us do things instead. It’s pretty crazy.”


This story was a collaboration by Caitlin E. Cox, L.A. McKeown, Michael O’Riordan, Todd Neale, and Yael L. Maxwell. Did we miss something? Let us know in the Comments section below what we left out, or have your say on Twitter using the hashtag #TopCardio2017.

Disclosures
  • Jeremias reports receiving institutional support from Philips/Volcano and Abbott Vascular and consulting for Philips/Volcano, Abbott Vascular, Boston Scientific, and Opsens.
  • Jang reports receiving educational grants and consulting fees from Abbott.
  • Wykrzykowska reports receiving grants/research support from Abbott Vascular and consulting for Abbott Vascular and St. Jude Medical.
  • Nasir reports serving on the advisory board for Quest Diagnostics and consulting for Regeneron.
  • Curtis reports receiving speaking honoraria from and serving on a data safety monitoring board for Medtronic and serving on the medical advisory board and adjudicating clinical trial results for Abbott (St. Jude Medical).
  • Masoudi reports serving as the chief science officer of the National Cardiovascular Data Registry. Guerrero reports receiving research grant support from Edwards Lifesciences, serving as a consultant/speaker for Abbott, and serving on the speaker’s bureau for Boston Scientific.
  • Svensson reports being an unpaid member of the executive committee for PARTNER trials I and II, chairman of the PARTNER publication committee, and an unpaid member of the executive committee of the COMMENCE trial, sponsored by Edwards Lifesciences.
  • Feldman reports consulting for Abbott, Boston Scientific, Edwards Lifesciences, and Gore.
  • Jaff reports consulting for Micell, Primacea, Vactronix, Venarum, and Volcano/Philips.
  • Foy, Miller, Little, Harris, and Meduri report no relevant conflicts of interest.

Former county EMS director files suit

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[dropcap]H[/dropcap]ardin County’s former EMS director has filed an anti-discrimination suit claiming he was wrongfully discharged from his job.

John Malcomson, a Radcliff resident, was suspended in June and discharged in July about one year after returning to work following a health emergency, which left him with a disability requiring some work-related restrictions.

In the four-page lawsuit filed last week in Hardin Circuit Court, Malcomson names Hardin Fiscal Court and Judge-Executive Harry Berry as defendants

Malcolmson asks the court for compensatory damages, reimbursement of legal fees and “any other relief to which he may otherwise be properly entitled.” No dollar figure is mentioned in the suit.

When the holiday weekend began Friday, defendants had not yet been served with the suit. Regardless, Berry said the county government would maintain its practice of declining comment on pending litigation.

During a public meeting in which Fiscal Court approved Malcomson’s firing, Berry said his recommendation stemmed from “misbehavior and inappropriate activity within the department.” Berry also said low morale and high turnover influenced his decision.

“Mr. Malcomson’s focus on the operations and business of the department is lacking. His availability is limited and unpredictable,” Berry said. “He routinely misses meetings, fails to meet expenses, demonstrates serious mood swings and is frequently disrespectful in his tone and demeanor toward his superiors and his subordinates.”

Malcolmson became emergency medical services director in August of 2014. As a result of an aortic dissection suffered in January 2014, he missed nearly 18 months of work. A complication required a partial left foot amputation and, according to the lawsuit, he was regarded as disabled by county government upon returning to work.

The lawsuit described a reprimand presented by Bryce Shumate, his supervisor, and Deputy Judge-Executive Jim Roberts following Malcolmson’s return to work. He was cited for failing to provide documentation of employee training. He claims in the suit the documentation had not been required during his initial two years of employment.

Malcomson, who missed work again in May 2017 with further complications related to the aortic dissection, said he was notified of his suspension June 22 and told by Berry he “was not capable of performing his job responsibilities.”

A civil suit provides only one side of a dispute. The county will file a formal response before the case proceeds in Hardin Circuit Court.

 Ben Sheroan can be reached at 270-505-1764 or bsheroan@thenewsenterprise.com.

Surgery saved the cop’s life. With a long recovery ahead, officers raise money to help

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[dropcap]A[/dropcap]fter an Horry County police officer was on duty patrolling last month, he suffered a traumatic heart injury and was rushed to a nearby hospital for life-saving surgery.

Now, 36-year-old KC Canterbury is home for recovery, but still faces a mound of medical bills as he heals.

“He’s one of those people that would literally do absolutely anything for anybody at any hour of the day,” said John Brantly, vice president of the Coastal Carolina Fraternal Order of Police Lodge #12. “He’s a very family oriented person, regardless of whether it’s blood family or blue family, you couldn’t find a better person.”

On the night of Nov. 25, Canterbury suffered from an aortic dissection and an aneurysm.

An aortic dissection is a serious condition in which the inner layer of the aorta, the large blood vessel branching off the heart, tears, according to Mayo Clinic. Blood surges through the tear, which causes the inner and middle layers of the aorta to separate — or dissect, hence the name.

An aneurysm is an “abnormal bulge or ballooning in the wall of a blood vessel,” Mayo Clinic explains. An aneurysm can rupture, cause internal bleeding and lead to death.

Canterbury was in critical condition when he was rushed to the hospital that night before he underwent an intensive surgery. He was released from the hospital on Dec. 11.

“It’s going to be a long road of recovery for him,” Brantly said. “That procedure takes an extreme toll on the body.”

Brantly started a YouCaring page to raise money for Canterbury’s expensive medical bills. As of Dec. 22, community members have raised $12,173 out of the $20,000 goal.

“Speaking for his family, they ask for prayers and support for his full recovery and the response from the community so far, has been overwhelming and nothing but positive, they greatly appreciate that,” Brantly added.

Canterbury has been in law enforcement for around 12 years and is the president of the Coastal Carolina FOP Lodge #12.

If you would like to donate, you can do so by visiting: www.youcaring.com/kccanterbury-1030062.

Brantly said checks are also being accepted, which you can pay to the order of SC FOP Lodge 12 and in the memo section write “KC Relief.” Checks can be mailed to the following address: S.C. FOP 12 P.O. Box 8455, Myrtle Beach, S.C., 29578.

What causes right side chest pain? Symptoms and treatment

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[dropcap]R[/dropcap]ight side chest pain is a commonly reported symptom experienced by many. While it may not have the same connotations as left-sided chest pain, which is often related to having a heart attack, right-sided chest pain can also be associated with several relatively unappreciated consequences.

The left side of the chest is often given more attention due to the fact that the heart resides more so on this side of the body. However, serious health problems can often present with right-sided chest pain that shouldn’t be neglected.

Anatomy of right side chest pain

The chest or thorax region of the upper body has a number of important organs that reside within it that may present with chest pain if they become compromised in some way.

In particular, the right side of the chest is home to several structures including the right side of the heart, the three lobes of the right lung, the ascending aorta, the pulmonary blood vessels, and the esophagus. All of these are interlaced with a rich and diverse network of lymph nodes and nerve fibers.

What causes right side chest pain?

Musculoskeletal causes:

1. Costochondritis and chest wall pain

Occurs due to inflammation of the cartilage connecting the ribs and the sternum (breastbone). Pain in this area of the chest can become so severe that it may mimic that of a heart attack or other heart-related condition. Treatment is focused on reducing pain until the condition resolves on its own.

2. Muscle strain

Also known as a pulled muscle whereby a muscle has become overstretched or torn. Often times, a muscle strain is the result of fatigue, overuse, or improper use of said muscle, most commonly involving the muscles of the lower back, neck, shoulder, and hamstring. Muscle strains can be a source of pain and decreased movement. Mild-to-moderate strains can be successfully treated with ice, heat, and anti-inflammatory medication, while more severe cases may require more intensive medical treatment.

3. Cervical or thoracic spine conditions

Conditions that result in the abnormality of the vertebral disc of the spinal column, such as disc disease or a compressed vertebra, may cause pain to be referred to the right side of the chest. Metastatic cancer of the cervical spine may also spread to other areas in the thoracic cavity lending to chest pain on the right side.

Heart and blood vessel causes:

1. Coronary artery disease

Due to hardening or narrowing of the blood vessels of the heart and is primarily due to the build-up of cholesterol and plaque in the inner walls of these vessels, known as atherosclerosis. As this condition progresses, less and less oxygenated blood is able to reach the heart, leading to chest pain (angina) or even a heart attack. Coronary heart disease is the most common type of heart disease and the leading cause of death for both men and women in the United States.

2. Pericarditis

Refers to the swelling and irritation of the sac-like layer of the heart called the pericardium. Inflammation of this membrane often causes chest pain when the irritated layers of the pericardium rub against each other. It is often difficult to determine the cause of pericarditis in the majority of cases; however, viral causes are often suspected.

3. Dissecting aortic aneurysm

A very serious yet relatively uncommon condition involving the large blood vessel of the heart. It is characterized by the inner layers of the aorta tearing apart from the outer layer, creating a pocket where blood can collect. This leads to further dissection of the two layers. If the blood-filled pocket ruptures, it can be fatal unless emergency medical treatment is provided. Aortic dissection is most frequently seen in men in their 60s and 70s.

Lung related causes:

1. Pulmonary embolism

Occurs due to blockage of one of the pulmonary arteries in the lungs. Pulmonary embolisms are due to free-floating blood clots, called emboli, that dislodge from another part of the body, often from the lower extremities after a condition called deep vein thrombosis. The blockage of blood flow to the lung can be life-threatening and should be treated right away to improve the chances of survival.

2. Lung cancer

Developing a tumor of the right lung or near the lymph nodes can cause pain on the right side of the chest. Pain caused by lung cancer may also travel to the shoulder blades. Unfortunately, there is no screening test for the early diagnosis of lung cancer, resulting in most cases being far along in the course of the disease before they are identified. Other symptoms of lung cancer include shortness of breath and a persistent cough.

3. Pneumonia

A serious and possibly life-threatening respiratory infection. It can be caused by viruses, bacteria, and fungi, resulting in the air sacs of the lungs filling with fluid or pus. It is estimated that about 900,000 Americans get pneumococcal pneumonia every year, and about five to seven percent of them die from it. Pneumonia can infect people of all ages, being most dangerous in those who are very young and very old, as their immune systems aren’t very strong. Symptoms of pneumonia often include coughing with phlegm or pus, chills, and difficulty breathing.

4. Pneumothorax

Refers to a collapsed lung that occurs when air leaks between the lung and the chest wall. As a result of this defect, air pushes on the outside of the lung and makes it collapse, allowing it to expand during the normal breathing process. A pneumothorax can be caused by a blunt or penetrating chest injury, certain medical procedures, or damage from underlying lung disease. Symptoms often include sudden chest pain and shortness of breath.

5. Pleural effusion

Occurs due to the buildup of fluid in the pleural space of the lungs, which is the area between the layers of tissue that lines the lung and the chest cavity. The type of fluid residing between these layers can be very helpful in the diagnostic process. If there is transudate fluid, heart failure or cirrhosis is very likely. If the fluid is exudative, lung infection or malignancy may be the cause.

6. Pleurisy

Also known as pleuritis, this condition refers to the inflammation of the pleura, a membrane consisting of a layer of tissue that lines the inner side of the chest cavity and the layer that surrounds the lungs. Symptoms are often described as sharp chest pain that worsens with breathing.

Digestive tract causes:

1. Gastroesophageal reflux disease (GERD)

Perhaps the most common cause of epigastric pain (pain felt in the upper chest), GERD leads to a burning sensation behind the sternum that is felt in the epigastric region. GERD occurs due to the regurgitation of stomach acids back up into the esophagus, leading to tissue irritation. GERD can be managed with lifestyle changes and the use of over-the-counter antacid mediation. However, some individuals may need stronger medication or even surgery to remedy their symptoms.

2. Esophageal spasm

Painful contractions of the esophagus can feel like sudden, severe chest pain that can last for a few minutes to a few hours. While in the majority of cases, treatment may not be required, sometimes spasms are frequent enough to prevent the passage of food and liquids from traveling down the esophagus.

3. Cholecystitis

Inflammation of the gallbladder typically caused by gallstones blocking the ducts that exit the gallbladder itself. Other potential causes of cholecystitis include bile duct problems and tumors leading to obstruction of bile flow. Symptoms often present as severe pain in the right abdomen, pain in the right shoulder or back, nausea, vomiting, and fever.

4. Gallstones

Also known as biliary calculi, these stones are formed due to imbalances in the level of cholesterol in the body. However, they may also form if the gallbladder does not empty efficiently. Gallstones may range in size from one millimeter to several millimeters and usually do not cause any problems until they are big enough to block the bile ducts, which lead to pain. Symptoms of gallstones present as severe abdominal pain, jaundice (yellowing of the skin and eyes), and fever.

5. Pancreatitis

A condition whereby inflammation has overtaken the pancreas, leading this organ to not function as it should. The pancreas is an organ of the body that produces enzymes that help with digestion as well as hormones to regulate how the body processes sugar. There are a number of different causes of pancreatitis, such as alcoholism and gallstones.

6. Peptic ulcer

Due to ulcer formation inside the lining of the stomach as well at the upper portion of the small intestine. Peptic ulcers often lead to pain that radiates up to the epigastric area. Ulcers can be the result of H. Pylori infection, long-term aspirin use, or the use of other painkillers such as ibuprofen and naproxen. Contrary to popular belief, peptic ulcers are not caused by stress or spicy foods, but can make the symptoms of an existing ulcer worse.

7. Liver cirrhosis

A late stage complication of liver disease that is characterized by scarring of the liver (fibrosis). The condition prevents this important organ from performing necessary functions, such as detoxifying harmful substances, cleaning the blood, and making vital nutrients. It can be caused by several diseases such as hepatitis and chronic alcoholism.

What are the symptoms of right side chest pain?

Depending on the underlying cause, right chest pain may also be accompanied by the following symptoms:

  • Feelings of pressure, squeezing, or fullness in the chest
  • Severe shooting pain in the arms, back, neck, jaw, or stomach
  • A cold sweat
  • Feeling weak, dizzy, or nauseous
  • Difficulty breathing
  • Fever
  • Persistent cough
  • Hoarseness
  • Heartburn
  • Unintentional weight loss
  • Jaundice
  • Palpitations
  • Lightheadedness

Treating your specific cause of right side chest pain will depend on the root cause of it. Some conditions may only require lifestyle changes and diet modification, while others require lifelong use of medications or even surgery. It is important to work closely with your doctor to find out all the things you can do on your own to reduce the risk of serious complications.

Should you worry about right side chest pain?

There are many causes that lead to the development of right sided chest pain. However, most cases are not directly related to the health of your heart. If you feel chest pain on your right side, it is relatively safe to assume that it is not caused by your heart and that another cause is most likely the culprit.

However, if you are experiencing extreme chest pain, regardless of the location, going to your local emergency room is highly recommended.

Heart Research UK’s ‘Sing for you Heart’

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[dropcap]C[/dropcap]elebrities, children and families from Essex are making a charity’s celebrity Christmas campaign viral – and are now calling on grime and hip hop superstar Stormzy to get involved.

Heart Research UK’s ‘Sing for you Heart’ sees members of the public and celebrities sing, donate and nominate – by uploading a short video of themselves singing on social media, texting SING to 70144 to donate £3 and then nominating up to three others.

Pioneering

The money raised will help further fund pioneering medical research into heart disease.
The viral campaign has reached over 12 million people online and seen support from Essex author and blogger Giovanna Fletcher (wife of McFly’s Tom Fletcher), Irish superstars Boyzone, Strictly Come Dancing star Brian Conley and Davood Ghadami, Britain’s Got Talent’s Alesha Dixon, Loose Women Linda Robson and Stacey Solomon, panto favourite Christopher Biggins, and ITV’s Good Morning Britain’s Piers Morgan.

For Heart Research UK Ambassador and Thurrock’s Vikki Renoldi-King, Sing for your Heart is more personal.

Vikki’s brother Julian died in 2014 from aortic dissection, a rare condition where the inner layer of the aorta tears. Julian, a father of three, was only 44.

Now the 40-year-old from Linford, who has raised £5,000 for Heart Research UK in the past by completing sponsored walks around Essex, wants the rest of the country to follow the county’s lead.

Vikki said: “Julian loved to play guitar and listen to music. When he was alive he would often send me songs to listen to and after he died I played his music often to feel close to him.

“Sing for your Heart is a special campaign, so to get friends and family involved to sing to raise money for heart disease just makes it all the more personal to us”.

Special

One member of the family got extra special support from her friends – 11-year old Annie Renoldi-Ludlow from Rectory Road, West Tilbury. Annie performed her Sing for your Heart video with her Youth Creations band, Young Vibes from Stanford-le-Hope. The group, made up of 7-11 year olds performed Stormzy’s Blinded By Your Grace.

Annie said: “We love singing, especially Stormzy songs. We had so much fun. If Stormzy heard it and did his Sing for your Heart, it would be amazing.”

Vikki added: “I’m asking all of Essex to share Young Vibes’ video, tweet @Stormzy1 with #STORMZYsingforyourheart and donate £3.

The Standard of Care

Professor of Surgery, University of Tennessee Health Science Center
 

In order to prevail in a medical malpractice action, the plaintiff must show, by a preponderance of evidence standard, that the defendant owed a duty of care to the plaintiff, the defendant was negligent in providing that care, the plaintiff was injured, and the legal cause of the injuries was the negligent care. All four of these elements must be shown for the plaintiff to win.

The most compelling type of medical malpractice case is the failure to diagnose a life-threatening condition which results in the death of the patient. Myocardial infarction, aortic dissection, certain malignancies, and neurologic injuries represent these types of cases. If the provider can show that he considered these types of conditions and he took steps to make the diagnosis, then he will likely win even if the diagnosis is missed.

There are false positives and false negatives for all diagnostic tests and the courts recognize this. In general, expert testimony is needed to confirm or deny that the provider did what a reasonable provider would do if faced with the same or similar circumstances. Expert testimony is required because most people do not have the knowledge or experience needed to make decisions on standards of care by themselves. Under the law, an expert can be used to educate the trier-of-fact to better understand the evidence or determine a fact in issue.

In most states and in the federal courts, an expert witness must be qualified by knowledge, skill, experience, training, or education so that he can testify in the form of an opinion or otherwise. Before an expert is allowed to testify, the court must act as a gatekeeper to determine if the expert’s testimony will substantially assist the trier-of-fact. The factors that the court will use in making this determination are (1) whether the scientific evidence has been tested, (2) whether the evidence has been subjected to peer review and publication, (3) whether a potential rate of error of the evidence is known, (4) whether the evidence is generally accepted in the appropriate scientific community, and (5) whether the expert’s research in the applicable field has been conducted independent of the litigation. These factors come from the Daubert v. Merrell Dow Pharmaceuticals, Inc. 509 U.S. 579 (1994) holdings which relate to what an expert witness is allowed to testify about in a malpractice action.

Prior to Daubert, the federal courts used the “generally accepted” standard which originated from Frye v. United States 293 F. 1013 (D.C. Cir. 1923)In Frye, the court held that novel scientific testimony is admissible in federal courts if the testimony had been “generally accepted” in the appropriate scientific community where it had originated; expert testimony must be based on scientific methods that were reasonably used and accepted. Most states then came on board with this standard and it had been used for over 70 years.

Most states and the federal Courts have adopted the holdings of Daubert but some have not. There are still 13 states which follow the standard of Frye.The Frye standard is a much easier to meet than Daubert. The courts that use the “generally accepted” standard reason that the jury should be allowed to rule on the relevance of the testimony and there should be no prior screening by a judge.

The “standard of care” is defined by statute in most states. For example, in Tennessee, it is “the recognized standard of professional practice in the profession and the specialty thereof, if any, that the defendant practices in the community in which the defendant practices or in a similar community at the time of the alleged injury or wrongful act occurred.” Most states do not have the community standard element that is in the Tennessee statute.

In medical practice, there are many conditions which now have recommendations for care and treatment. These recommendations come from committees comprised of recognized experts in the field. I was at a lecture for continuing legal education where a well-known plaintiff’s attorney stated that, as far as he was concerned, the “best practices” paradigms recommended by these committees were now the “standards of care” and any health care provider who did not follow the paradigms was committing medical malpractice. He was wrong.

Most, if not all, of the publicized treatment recommendations have a disclaimer which recognizes that it is up to the treating clinician to decided on the proper care of a particular patient. The law has not changed; the standard of care is still the care that would be provided by a reasonable physician who is faced with the same or similar circumstances. If a reasonable clinician would not have followed the committee’s recommendations, then the standard of care may still have been met.

Here is an example where the paradigm may not be the standard of care. Under the committee recommendations, a person who presents to the hospital with an acute coronary syndrome should be given morphine, oxygen, aspirin and nitrates. According to the above mentioned plaintiff’s attorney, a person not getting all elements of this treatment regimen would be the victim of malpractice. However, physicians would not give morphine to a person with a low blood pressure or to someone who is allergic to the drug. A patient who has severe chronic obstructive pulmonary disease may stop breathing if given supplemental oxygen. A person who has gastrointestinal bleeding or is allergic to aspirin should not be given that drug. We know from TV commercials that a person on Viagra or Cialis should not take nitrates as that could lead to a sudden dangerous drop in blood pressure.
 

Opposing attorneys will try their best to discredit the expert witness on cross-examination and they have many weapons in their arsenal to accomplish this goal. One strategy is to let the jury know how much has already been paid to review the medical records, study deposition testimony and answers to interrogatories, and how much is being charged per hour to do the reviews, give testimony at depositions, and testify at trial. The amounts can be substantial and many professionals make a significant income performing as an expert witness. If it can be shown that a particular witness has been paid a lot of money, then the jury may conclude that his opinion is being bought; the credibility of the witness will suffer accordingly.

Although there are many other ways to attack an expert on cross-examination, one of the best is to show the jury that he may not be an expert at all. This can be done by exposing weaknesses in the expert’s curriculum vitae. A national survey of 2.6 million resumes done in 2003 showed that 41 percent lied about their work experience and 23 percent lied about their credentials or licenses. A surprising 41 percent lied about their education (Thomas A. Buckhoff, Preventing Fraud by Conducting Background Checks, CPA J., Nov. 2003). Opposing attorneys now routinely check the backgrounds of medical expert witnesses and they will even look at social media sites to see if they can find some incriminating information that can be used to attack their credibility.

If it can be shown that the medical expert was willing to embellish on his qualifications, it is logical to assume he has embellished his medical opinions, also.

There are few trial lawyers that can show superior knowledge to the expert in the medical field under discussion. After all, they are lawyers and it is unlikely they have ever treated an actual patient. Book knowledge is just not enough to be a good physician and that is probably why it is called the “practice of medicine.” By practicing, you are hopefully improving your knowledge and skill as a physician all the time.

If the physician can show he used his best clinical judgment at all times while caring for the patient, he will likely win his case even if the results were not good. Physicians are forced to make judgments, some of which do not work out well for the patient. These decisions are made with the best data available; they cannot rule out every single diagnosis or provide perfect care. The courts and the juries recognize this and will generally rule in favor of the physician who has used his best judgment and done it in a timely fashion. The physician can be his own best medical expert witness in this regard.

Dr. Weiman is the author of two books, Medical Malpractice and Fundamental Issues in Health Care Law.

Dr. Weiman’s website is www.medicalmalpracticeandthelaw.com

Anthem’s new policy will scare away patients who need the emergency room

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by Dr. Aida Cerundolo |  

I once cared for a patient in her 20s who came to the emergency room for a sore throat and a rash. While she was in no acute distress, she explained that her throat hurt and unusual bumps were erupting on her hands.

But then she mentioned starting a new antibiotic. My internal alarms sounded. Her symptoms were signs of a potentially life-threatening condition that required specialty services not available at my small hospital. I arranged for transfer to a tertiary care center. The next week I received a follow-up letter from her care team. No more than 36 hours after I saw her, she was in the intensive care unit, on a ventilator, fighting for her life.

The lesson is that even if not every rash and sore throat is a life-threatening condition, life-threatening conditions don’t always present themselves as obvious emergencies.

Anthem Inc., a for-profit managed healthcare company, appears to disagree. Beginning Jan. 1, 2018, Anthem will not cover the cost of services rendered in a New Hampshire emergency room for conditions deemed, after the fact, to be non-emergent. If Anthem determines that a medical problem could have been handled at a non-emergent clinic, the patient is on the hook for the cost. This rule is also being more diligently enforced in Kentucky, Virginia, Georgia, and Missouri.

Anthem is justifying the move by pointing to significantly higher emergency room costs compared to non-emergent clinics, citing such so called “non-emergency” services as annual sports physicals, pregnancy tests and ingrown toenails. They argue this cost is inevitably passed on to consumers.

However, the list of Anthem’s non-emergent diagnoses does not stop there. Under this enforced policy, more ambiguous complaints like chest pain with breathing and bloody urine can also be deemed unworthy of an ER visit. The American College of Emergency Physicians has uncovered almost 2,000 of these non-emergent diagnoses in Missouri alone.

Hindsight is always 20/20. But patients don’t have the benefit of a medical evaluation and test results, nor the medical training to help them decide on their on whether their condition merits emergency treatment. And for that reason, the Prudent Layperson definition was added to the federal Emergency Medical Treatment and Labor Act (EMTALA) in 1994, defining an emergency condition as one that would lead a prudent layperson, with an average knowledge of medicine, to believe that his or her health is in jeopardy. It is the patient’s presenting symptoms, not the final diagnosis, that legally determines authorization and payment for emergency claims.

But even emergency physicians are not soothsayers. EMTALA mandates that no patients are turned away from the emergency room without a medical screening exam to rule out dangerous conditions. If a patient presents with chest pain, the bucket of possible diagnoses is overflowing, from benign ailments like muscle strain or heart burn, to life-threatening conditions like heart attack, pulmonary embolism or aortic dissection. Testing is often required to tease out the difference.

And, yes, amid these casualties, there may also be some reduction in non-emergent ER visits.

Rather than penalizing patients who believe their condition warrants an emergency visit, incentivizing them when they utilize appropriate services instead will likely also reduce non-emergent ER visits, and not deter patients from seeking appropriate emergency care when they should. By denying payments for certain non-emergent diagnoses determined after the fact, Anthem is merely pushing a healthcare cost hot potato off their lap and into the arms of legally obligated emergency care providers.

How many patients will suffer preventable injury or even death because they now fear a bill for a legitimate emergency department visit? That hindsight will be 20/20.

Dr. Cerundolo is a physician practicing emergency medicine in New Hampshire.

 

 

Moderate exercise training improves some of the Marfan syndrome symptoms in mice

Regular physical activity is a common therapy for people with cardiovascular problems, but not recommended to those with Marfan syndrome, a rare disease of the connective tissue affecting the cardiovascular system. A study conducted jointly by the University of Barcelona and the August Pi i Sunyer Biomedical Research Institute (IDIBAPS) has analysed for the first time this medical recommendation, analysing the impact of exercise in the development of the disease in mice. The results, published in the scientific journal Journal of the American Heart Association, show that moderate exercise reduces the progression of aortic aneurysm, one of the most severe symptoms of the disease, which can cause arteries to break.

 

Hypothesis without experimental evidence

Physical activity increases the blood the heart pumps per minute. This increase has an impact on the aorta. “So far, it was thought that this mechanic impact, together with a discrete increase of the arterial pressure, could have negative effects on a weak arteria, like the case of patients with Marfan syndrome, and therefore it would dilate faster if the patient exercised,” says Gustavo Egea.

To test this hypothesis, researchers analysed the effects of  on rice with Marfan disease. “During the five months of the experiment, the aorta of those mice who did not exercise dilated twice compared to those mice that were not ill. Mice which exercised experienced a reduction of this dilation until it was indistinguishable from those without the disease,” says Eduard Guash. Also, among the beneficial effects, researchers also saw that moderate exercise for five months reduced the size of the heart (cardiac hypertrophy) compared to those mice that did not exercise.

“The new results go against a clinical concept that was accepted without any  to prove it: it said that all  increased the risk of speeding up the aneurysm progression” says Gustavo Egea.

Thinking lifestyle recommendations twice

Although results in animals should be carefully interpreted before bringing them to patients, researchers highlight that the study provides experimental data that was not available before. “Our work opens the door to conducting studies on humans, but does not verify directly the non-selective recommendation of physical activity to patients with Marfan syndrome,” says Gustavo Egea.

Moreover, the researchers note that the study is focused on the impact of moderate exercise, which is the one recommended to people in general and which has been proved to bring cardiovascular benefits. “We did not face the effects of intense and long exercise and we cannot apply our results to other kinds of  –other than resistance,” says Eduard Guasch.

Marfan syndrome

Marfan syndrome is a genetic disease caused by the mutation of a gene that codifies fibrilin I protein, one of the two main compounds of  that make up the . As a consequence of this mutation, the elastic fiber assembly in tissues is wrong, and therefore the function of relaxation is lost and tissues get damaged faster.

All tissues with elastic fibers or fibrilin I microfibriles are affected, like skin that gets stretch marks, or lungs with emphysema, and the eye lens that moves and causes blindness. The most significant one out of all these dysfunctions is the accelerated weakening of the ascending aorta, which leads to  and the following dissection and breaking of the aorta.

These clinical manifestations are what is known as Marfan syndrome, which, despite being a minority disease, has a high prevalence of 1/5,000 patients and is hard to diagnose.

People with Marfan are tall with disproportionately large extremities. The average life of non-diagnosed people is around 40 years old, and around 50% of people with this disease are not diagnosed. In Catalonia, there can be around 1,500 people with it. The diagnostic is made with a study of clinical manifestation with a score. When in doubt or verification a genetic analysis can be carried out. Nowadays, the only effective therapeutic solution is surgery, and diagnose and regular monitoring of the aneurysm progression with imaging techniques are essential to increase the life of the patients.

 Explore further: Researchers reverse heart failure in Marfan mice

More information: Aleksandra Mas‐Stachurska et al. Cardiovascular Benefits of Moderate Exercise Training in Marfan Syndrome: Insights From an Animal Model, Journal of the American Heart Association (2017). DOI: 10.1161/JAHA.117.006438 

After cheating death, time to enjoy our beloved Christmas Tournament

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[dropcap]A[/dropcap]fter cheating death, time to enjoy our beloved Christmas Tournament.What I do know is, I should be dead. Two different cardiologists told me 80 percent of the time the aortic dissection I had would have been fatal.

Wikipedia defines an aortic dissection as “an injury to the innermost layer of the aorta which allows blood to flow between the layers of the aortic wall, forcing the layers apart.”

Let me tell you, you don’t want the layers of your aortic wall forced apart.

But with a lot of love from family and friends and a world-class doctor in Dr. Stanley Tam, I’m back.

For the first time in 42 years, I missed the highlight of my year last December, the annual Commonwealth Motors Christmas Classic. For my money, the premier boys basketball tourney in the state.

But it’s not going to happen again! I’ll be at Methuen High with bells on Dec. 23, 27 and 29.

Here is my story.

It was just about a year ago. I had returned from the Christmas Tourney banquet at DiBurro’s in Haverhill, written my story and proofread The Eagle-Tribune Monday sports pages.

I was heading home at about 2 a.m. the morning of Dec. 12. Suddenly, I wasn’t feeling well and/or my car broke down in an early-morning snow storm. It may have been both.

I woke up my wife, Yadira Betances Muldoon, and she was going to pick me up on the side of the road on Rte. 495 in Lawrence.

She sensed something was wrong and thankfully called the police. A kindhearted state trooper, I still don’t know his name, took good care of me and that was blessing No. 1 in a series of blessings that enable me to write this story.

MedFlight to Boston

The next thing I remember it was three days later. I was in intensive care at St. Elizabeth’s Hospital in Boston, where I had been MedFlighted that Monday morning from Holy Family Hospital in Methuen.

After an 18-hour emergency surgery, I now had a patched up aorta, a nasty 9-inch scar on my chest and too many tubes to count.

Facebook pronounced me well on the comeback trail. But the well-meaning friend couldn’t have been more wrong.

At about the time I was getting flooded with relieved compliments on social media, I was actually being rushed to a second 12-hour emergency surgery for internal bleeding.

Against doctors’ advice

Drip by drip I heard I was less than an ideal patient. I pray that was due to medication and the extraordinary situation I found myself in and not that I was once again being a jerk.

But when you are comatose for a few days, then semi-comatose, well, that’s my excuse.

I was pulling out all my tubes to the shock of my saintly nurses and wife. Hospital orderlies had to tie me to the bed.

One day I was frantically calling every number in my cellphone looking for a ride home to a comfortable bed, a stocked refrigerator, a computer with Wi-Fi and a clicker I had mastered.

Four things St. Elizabeth’s couldn’t offer.

I tried to bribe one colleague with $300 for a ride from Brighton to Methuen. Since I probably don’t have $300 to my name, that was pretty preposterous.

About 30 horrified people called my wife, “Um, Yadira, did you know Mike was planning on leaving the hospital against doctors’ advice.”

I still can’t believe that one, but I looked all sorts of doctors and administrators in the eye and said, in so many words, “Get me the %^&*# out of here.”

I actually told them, “I’m going home to sleep and will be back later.”

The fact they were some of the best medical minds in the world and I was a sportswriter who flunked Mr. Cayot’s sophomore biology class in high school, didn’t dawn on me.

Thankfully, enough relatives and friends convinced me I didn’t know what I was doing and all but restrained me.

If you have to die, you don’t want it to be because of Irish stubbornness.

But shortly before Christmas, I was released. I figured I’d dance an Irish jig and then take in the Christmas Tourney. Maybe cover the tourney for my 31st straight year.

Not so fast. I tried to walk down the hall at St. Elizabeth’s and nearly collapsed due to overwhelming fatigue.

No, I was bed-ridden for another month.

Defying long odds

I’m not a very introspective man. When I heard those chilling “80 percent dead” odds, my reaction was something like: “Wow, aren’t I lucky. Pass the clicker.”

My second reaction was that this will give me an excuse to stop dying my hair after 35 years.

But I am blessed to be here and I wonder if I would be here if it weren’t for my wife, Yadira, who moved into St. Elizabeth’s for 12 days and was there every step of the way.

I was hoping Yadira was with me in the helicopter ride to St. Elizabeth’s so that might count as a unique Christmas gift. She wasn’t, it didn’t. I’d better get her some Louis Vuitton red shoes this Christmas!

So many people to thank

I’m still working on some cool stories to explain the 9-inch vertical scar down my chest and two-inch horizontal one.

Maybe something like: “The Gronkowski brothers were acting up and I got right into Rob’s face …”

There are so many people who were so good to me. My wife, my mother, Joanne, my stepson Gabriel Martinez and my four siblings (Bobby, Kevin, John and Maura) certainly top the list.

All my Tribune sports colleagues were wonderful especially sports editor Bill Burt, a regular at St. Elizabeth’s, and Dave “Duffy” Dyer.

Even today, if I’m having a bad day I’ll go to the article Duffy wrote: “No. 1 Christmas wish: Full recovery for Mike.”

It’s an immediate pick-me-up.

My friend, former Andover basketball great Ted Kelley, hurried back from some far-flung locale thousands of miles away.

So he could be in my room for an hour while I was comatose!

St. E’s had a special nurse, and again I hate to say I don’t even know her name.

But when you have urine and feces on you, cramped in the bed at my height (6-foot-6) and frustrated beyond belief with no computer handy, a gifted and kind nurse can make all the difference.

Through the entire ordeal, and I’ve been just about 100 percent for 8-9 months now, this is what I was struck most by: People are so nice and so caring.

Other people in the newsroom I could never thank enough include photographer Carl Russo, community news editor Betsy Curry, who made a massive plate of her world-famous brownies when I returned, and our former night editor Joel Barrett.

Time to go to work

When a major storm hit, I panicked. I’ll be housebound for a week. I’ll have to miss work … on the heels of missing almost two months! The guys had already worked themselves to the bone carrying me and now this.

Muldoons are a lot of things, but we’re workers. I’ll never forget my the 50-something-year-old mother trudging three miles through 20 inches of snow to get to her job one time as a nurse at Phillips Academy.

And 40 years later, she has never mentioned it once.

But now I was going to be “that guy” everyone wanted to strangle.

So self-pity was setting in. Would I even be able to go back to my job which I enjoyed so much?

Then I hear the early-morning hum of a snowblower. It was my Methuen neighbor, PMA basketball coach Brian Martin, cleaning every nook and cranny of the driveway.

And he did it the entire winter, refusing to take a penny. What a guy.

Another huge boost came from Central Catholic. Raider athletes and coaches put together a 3-minute video, which was better choreographed than “Hamilton.”

I’ll never be able to thank them enough for it.

Love of Christmas Tourney

In addition to a life-and-death medical situation, taking enough drugs to put down an elephant, and battling what seemed to be depression, I so missed “The Christmas Tourney.”

The 42nd annual Commonwealth Motors Christmas Classic was right around the corner and for the first time ever I wouldn’t be there. Heck, I’d covered it for the last 31 years and it was always the highlight of my writing career.

No. 2? I couldn’t even answer that it was so far down the list.

Since my father is gone, I can admit it. I used to skip church to go to those early tournaments. It was hoops heaven.

I watched my buddies Ted Kelley and the Perry brothers become legends. I watched in awe and was determined to properly capture the greatness of Scott Hazelton and Carson Desrosiers and all those great Central Catholic teams.

I always wished I was as cool as Lawrence legends Rigoberto Nunez and Elinton Rosario.

This was my baby, my turn to shine. And it was taken away.

I might not know as much about sports as Hector Longo. Or have Bill Burt’s resume. Or Dave Dyer’s work ethic.

But dammit, I would leave no stone unturned so that you might get the occasional, “Hey, I really enjoyed that Christmas Tourney story you did on …”

So this year will be special. More special than people will ever know.

Painless aortic dissection presenting with multisystem organ failure and owl’s eyes sign of the spinal cord

A 72-year-old woman presented to the hospital with 3 days of emesis, anorexia and generalized fatigue without any report of chest pain. Her physical examination was significant for mild confusion and bright red blood per rectum. On presentation she had bilateral lower extremity weakness, but was able to move both lower extremities; dorsalis pedis pulses were present bilaterally.

Initial laboratory examinations demonstrated a white cell count of 16.7 K/μL, creatinine of 3.0 mg/dL, aspartate aminotransferase/alanine aminotransferase of 1189/382 U/L, lactate of 4.5 mmol/L and a troponin of 0.52 ng/mL. ECG was unremarkable. An initial chest X-ray showed a dilated aortic arch and a modestly widened mediastinum.

A CT scan of the chest was not done. Several hours after presentation, the patient was noted to have flaccid lower extremities and diminished distal pulses, but with no skin changes or signs of distal ischaemia.

Duplex ultrasound of the lower extremities demonstrated biphasic waveforms of distal vessels with no areas of occlusion or evidence of embolisation. Transthoracic echocardiogram revealed a small pericardial effusion with grossly normal ventricular function; the aorta was not well visualised…….

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Northwestern Memorial Hospital Surgeon First in Illinois to Repair Damaged Aorta with “Frozen Elephant Trunk” Graft

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CHICAGO, Dec. 15, 2017 /PRNewswire-USNewswire/ — Phillip Lonergan has hiked the Himalayas, the Alps, the Pyrenees and the Rockies, but an aortic aneurysm — a potentially deadly bulge in the largest artery in the body — threatened to be the toughest challenge of his life.

Northwestern Medicine Logo (PRNewsfoto/Northwestern Medicine)

Now, the Chicago-based graphic designer is on his way to exploring new trails after a first-in-Illinois procedure where Northwestern Medicine cardiac surgeon S. Chris Malaisrie, MD repaired and stabilized his damaged aorta with an investigational device known as a “frozen elephant trunk” graft because of its shape and stiff material.

The Thoraflex™ Hybrid Device is used to repair an aorta damaged from either an aortic aneurysm, or a bulge or ballooning in the aorta’s wall, or dissection, which is a tear in the aorta’s wall. The aorta runs from the heart through the chest and abdomen, carrying oxygen-rich blood to the body.

The frozen elephant trunk graft is designed to repair the damage in one surgery when previously, surgeons required two separate procedures to make the complicated repair.

“This device makes the procedure easier for the patient and reduces the amount of time the patient is on the heart-lung machine during surgery,” said Dr. Malaisrie, who is co-director of Northwestern Medicine’s Thoracic Aortic Surgery Program and an associate professor of surgery-cardiac surgery at Northwestern University Feinberg School of Medicine. “It’s a potential breakthrough in the surgical treatment of arterial disease, and we are pleased to be part of this clinical trial investigating its efficacy.”

Lonergan’s aortic bulge happened in 2010, and was repaired successfully at the time at Northwestern Memorial Hospital. However, the repair wasn’t permanent and in 2016 Dr. Malaisrie told him he qualified for a clinical trial investigating the frozen elephant trunk device.

Lonergan said he always knew he would need additional surgery on the aorta, and was pleased there was an investigational option.

“I’ve known this was coming for six years,” he said. “Everybody here at Northwestern Memorial Hospital has been great, from the surgeon and probably dozens of other staff who saved my life in 2010 to Dr. Malaisrie, who extended it and spared me an additional surgery. I looked at this clinical trial as my chance to give back to medicine.”

“This has helped me get back on my feet,” he added. “Now, I want to see more of the United States, and maybe travel to the Middle East.”

The Thoraflex™ Hybrid IDE study will enroll as many as 80 participants in 14 centers in the United States. Northwestern Medicine hopes to enroll 10 individuals. Dr. Malaisrie has performed nine surgeries as part of the trial.

The Bluhm Cardiovascular Institute is part of the Northwestern Medicine health system, with multiple sites of care in Chicago and the region. Northwestern Memorial Hospital currently is ranked first in in the United States for heart failure survival, second in the United States for the survival of stroke and in the top 10 for the survival of heart attack, the three most dire cardiovascular health threats. Northwestern Memorial Hospital’s heart and heart surgery program is ranked seventh nationally and first in Chicago, Illinois and the surrounding states by U.S. News & World Report. For more information or to make an appointment with a cardiovascular specialist, visit heart.nm.org or call (312) NM-HEART.

Cision View original content with multimedia:http://www.prnewswire.com/news-releases/northwestern-memorial-hospital-surgeon-first-in-illinois-to-repair-damaged-aorta-with-frozen-elephant-trunk-graft-300572065.html

SOURCE Northwestern Medicine

RSNA News: CT Shows Enlarged Aortas in Former Pro Football Players

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Former National Football League (NFL) players are more likely to have enlarged aortas, a condition that may put them at higher risk of aneurysms, according to a study presented at the annual meeting of the Radiological Society of North America (RSNA), which took place from November 26 to December 1 in Chicago.

The aorta, the largest artery in the body, carries blood from the left ventricle, the heart’s main pumping chamber, to the rest of the body. The short section that rises from the left ventricle and supplies the coronary arteries with blood is called the ascending aorta. Enlargement, or dilation, of the ascending aorta can increase the chances of a life-threatening aneurysm. Risk factors for dilation include high blood pressure, smoking and connective tissue disorders.

Patients whose ascending aortas are more than 4 cm in diameter are generally considered to have dilation, which can progress over time and potentially weaken the wall of the aorta,” says study author Christopher Maroules, MD, formerly of the University of Texas Southwestern Medical Center in Dallas and current chief of cardiothoracic imaging at the Naval Medical Center in Portsmouth, Va.

For the new study, Maroules and colleagues evaluated whether past participation in the NFL is associated with increased prevalence of ascending aortic dilation. The research arose from observations made by the study’s principal investigator Dermot Phelan, MD, PhD, from Cleveland Clinic, who has worked closely over the years with the NFL, studying the cardiovascular health of retired players.

The researchers compared 206 former NFL athletes with 759 men from the Dallas Heart Study who were older than age 40 with a body mass index greater than 20. They obtained imaging data using cardiac gated non-contrast CT, a technique that allowed them to “freeze” the motion of the heart by synchronizing the CT to the electrocardiogram. They also obtained coronary artery calcium scores, a measure of atherosclerotic plaque.

Compared to the control group, former NFL athletes had significantly larger ascending aortic diameters. Almost 30% of the former NFL players had an aorta wider than 4 centimeters, compared with only 8.6% of the non-players. Even after adjusting for age, body mass and cardiac risk factors, former NFL players were still twice as likely as the control group to have an aorta wider than 4 centimeters.

The coronary artery calcium scores were similar in both groups.

“In former NFL athletes, there was a significantly higher proportion of aortic dilation compared to our control group,” says Maroules. “This process is likely not associated with atherosclerosis cardiovascular disease, because when we compared coronary calcium we found no significant difference between the two groups.”

The results suggest that some type of remodeling process occurs in the aorta of athletes who engage in repeated strenuous exercise, according to Maroules.

“It remains to be seen if this remodeling sets athletes up for problems later in life,” he says. “We’re just scratching the surface of this intriguing field, and imaging can play an important role in it.”

Former Eagle Jon Dorenbos: Every day that I’m here is another day I shouldn’t have had

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Jon Dorenbos experienced a treat on Thursday. It was the first Thanksgiving Day he was home in Huntington Beach, Calif., with his family in almost 20 years.

The beloved former Eagles long snapper had no doubt much to be thankful for, as he jokingly kidded about rubbing his belly stuffed with turkey and gradually working his way up to a life-long reminder of how fortunate he is — the eight-inch-long vertical scar that runs down the middle of his chest.

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Then there were those other things, too, he was thankful for, like being able to talk, feeling the water on his face when he took a shower, rolling the window down and feeling the breeze when he drove, hearing the oil sizzle in a pan when you crack an egg. The little things we all tend to take for granted bring the 37-year-old, 14-year NFL veteran to tears.

“I’m crying all of the time,” said Dorenbos, who underwent heart surgery on Sept. 12 to repair an aortic aneurysm that was discovered after he was traded from the Eagles to the New Orleans Saints on August 28. “Hey, I think tattoos are cool, but I think scars are sexy. Now I have one. Scars don’t bother me. The chain of events that happened, it’s crazy. The doctor in New Orleans put a stethoscope to my back, I took three breaths and wound up in the hospital.

“I was told by multiple surgeons that if I got a good hit to the chest, the percentages for me were significantly higher for me dying than living. They all said I probably was going to die on the field.”

Instead, Dorenbos is gradually getting stronger with each passing day and planning out his future after football. It’s not the way he wanted to leave the game since he was on the Saints, who are 8-2 and lead the NFC South, and since he wasn’t ready to retire just yet.

Dorenbos finds himself much more informed about the human heart, which if anyone who knows his backstory would never question. He also found out he had a long-undetected birth defect.

Most people have a three-leaflet valve (tricuspid). Dorenbos only had two. This undetected birth defect is how actors John Ritter and Alan Thicke died. Actor Bill Paxton died during surgery to repair type-A aortic dissection.

It was hard to leave football, Dorenbos explains, but he has a very strong reason why.

“People come up to me all of the time and tell me how great the Saints and Eagles are doing, and I’m really happy for my friends on both teams,” said Dorenbos, who turned his phone off for a month and found out he received over 2,000 messages. “Well, my only other option was dying. Maybe if I was released by the Saints and still felt healthy, I would have given it another shot. But when your only other real option was a strong chance of dying, all of a sudden it’s not that bad to be done.”

NoneCOURTESY JON DORENBOS/FOR PHILLYVOICEJon and Annalise Dorenbos, following the beloved ex-Eagle’s open-heart surgery in September.

Dorenbos, however, is far from done.
He’s doing work with the “Ellen DeGeneres Show,” and there is a movie in the works about his life and career. He also plans on being an advocate for the rare type of heart defect he had with Dr. Joseph E. Bavaria, who performed the surgery on Dorenbos and is employed by Penn Medicine and considered the best in the world at bicuspid valve repair and aortic aneurysms.

The noted magician who captured the nation’s attention as a finalist in 2016’s “America’s Got Talent,” Dorenbos has a new man in his life, a dog he calls “Saint.” He already has 2,000 followers on Instagram.

“You realize how much people are pulling for you. I love Philadelphia. I love Eagles fans.”

– Jon Dorenbos
He says he’s at about 50-percent physically.

He’s hoping to have an involvement with the Eagles in his future. The Eagles and Philadelphia, he says, have been a large part of his life that he will never forget.

Then there’s the movie project and he has a book in the works. He has about 150 pages written and the manuscript is being presented to New York publishers. Dorenbos is also very close to Mike Tollin, the director of the movie “Radio.” The two have been talking about a project involving Dorenbos’ life.

Dorenbos may never have another bad day in his life. All he has to do to remind himself of where he was, and where he is, is to touch that scar.

“I’m in a good situation,” Dorenbos said. “My fingers will feel that scar every day the rest of my life. There are parts of the scar you can feel through my t-shirt and parts of it still hurt. Every time I see my friends and my Eagles family, I just cry. Every day that I’m here is another day I shouldn’t have had if things went the way they were going. A lot of times what I had goes undetected.

“I want to create an awareness of this. It’s something that I’m talking with Dr. Bavaria about. You have to understand that the Eagles will always be a part of me. Keep in mind that there will always be a part of me that’s bummed that the Eagles are killing it and I was there for so long and I’m not able to be a part of it. That sucks. When I think of the other alternative, it’s not so bad. And Ellen DeGeneres gives me something to look forward to every day. She’s an amazing woman, allowing me to do so much. She’s not only a kind-hearted woman, she’s willing to help so many others.”

It took a while for his appetite to come back. He lost about 30 pounds due to the surgery. He’s around 240 now. A few days after he was released from the hospital, Dorenbos and his wife, Annalise, who’s been an unsung hero through this whole process, went to a local bar in the Philadelphia Navy Yard. It was in the middle of the day. No one approached them to ask for an autograph. Some patrons peered up from their tables in recognition of the former long-time Eagle.

When Dorenbos left with Annalise through the patio section of the bar, one man stood up and gave Jon a slow clap. Soon, it was followed by others. By the time he drove away, a good handful of customers were clapping and cheering for him.

“You realize how much people are pulling for you,” Dorenbos said. “I love Philadelphia. I love Eagles fans.”

He also still loves magic.

“The first time I picked up a deck of cards I enjoyed it. Hearing the riffle shuffling a deck of cards is one of my favorite sounds of all time. After the surgery, I would pick up the cards and put them back down. Then one day I got the cards in my hands and started playing around again.”

Annalise came over and kissed him, saying, “It was good to see you doing that again.”

mum Lorna Arduino was rushed in to Tunbridge Wells Hospital

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When Sevenoaks mum Lorna Arduino was rushed in to Tunbridge Wells Hospital having developed a life-threatening heart condition, everyone feared the worst.

But a year on and the 46-year-old wowed staff by walking back in to the emergency department, to personally thank some of the people who saved her life.

Mrs Arduino had been walking her dogs on November 14, 2016 when she suddenly collapsed.

When she came to, she couldn’t move but managed to call for help from her mobile phone.
The mum-of-three was rushed to the hospital, in Pembury, where she was seen by A&E Consultant, Dr Angela Feazey, and Emergency Registrar, Dr Megan Purcell-Jones.

They knew immediately that there was something very wrong and referred her for an emergency CT scan, which discovered Mrs Arduino had suffered an aortic dissection – a very serious condition in which the inner layer of the aorta, a large blood vessel branching off the heart, tears.

“Having got through something so serious, I fully intend to go out and live my life – and that’s down to the people I was so lucky to have been treated by when I was brought into the hospital” – Lorna
Blood surges through the tear, causing the inner and middle layers of the aorta to separate. Around one in five patients with an aortic dissection die before they get to hospital and many don’t survive surgery.

A decision was quickly made to transfer Mrs Arduino to King’s College Hospital in London, where she underwent 10 hours of emergency specialist surgery and spent 10 days in a coma. She spent three and a half weeks in ITU and a total of five weeks in hospital.

She said: “Saying thank you will never be enough. It’s absolutely terrifying to be told that you might not see tomorrow but when you’re surrounded by people who are so compassionate and you have total confidence that everything that could be done is being done, it makes a huge difference. They were absolutely amazing.

“I was told by my surgeon at King’s that the reason I am alive is down to the fact that the staff who cared for me at Tunbridge Wells Hospital acted so quickly. I can’t explain how grateful I am.

“My recovery is ongoing but I can walk, swim and take part in gentle exercise, although I get tired easily and have to make sure that I rest regularly and keep my blood pressure down.

“Having got through something so serious, I fully intend to go out and live my life – and that’s down to the people I was so lucky to have been treated by when I was brought into the hospital last year.”

Dr Feazey said: “It was wonderful for us all to see Lorna. We were absolutely amazed at how well she looks.
“When she came in to us last year, she had gone from being fine to being catastrophically unwell in a matter of hours and we weren’t at all sure that she would survive.

“So often, we treat people but don’t find out what happened to them after they leave our care so to be able to give her a hug and hear from her first-hand meant the world to all of us.”

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