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Pubblicazioni recenti - cardiopulmonary
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Surgical Decision-Making for Rectal Prolapse: One Size Does Not Fit All.
Postgrad Med2019 Sep;():. doi: 10.1080/00325481.2019.1669330.
Lee Angela, Kin Cindy, Syan Raveen, Morris Arden, Gurland Brooke,
Abstract
: Surgery remains the only known treatment option for rectal prolapse. Although over 100 abdominal and perineal procedures are available, there is no consensus as to which intervention is best suited for an individual. This retrospective cohort study describes the patient- and disease-related factors involved in making surgical recommendations around rectal prolapse in a single surgeon experience. : 91 consecutive patients ?18 years old diagnosed with external and/or high grade internal rectal prolapse were assessed and were prospectively entered into an IRB approved registry. Information on patient symptoms, comorbidities, exam findings, surgeon judgement and patient preference was collected. Treatment recommendations (abdominal, perineal, or no operation) were analyzed and compared. : Surgical intervention was recommended to 93% of patients. Of those, 66% were recommended robotic abdominal procedures: 75%, robotic ventral mesh rectopexies; 16%, resection rectopexies; and 9%, suture rectopexies. On univariate analysis, patients with older age, higher ASA scores, presence of cardiopulmonary morbidity, pain as a primary rectal prolapse symptom, rectal prolapse always descended, and surgeon concern for frailty and general anesthesia were associated with recommendations for perineal operations (p<0.05 for all). However, on multivariate analysis, only age and concern over prolonged anesthesia remained correlated with recommendation for perineal surgery. Of patients >80 years of age, 15% were recommended an abdominal approach. : With multiple options available for treatment of rectal prolapse, treatment recommendations remain surgeon-dependent and may be influenced by many factors. In our practice, robotic ventral mesh rectopexy was the most commonly recommended operation and was offered to carefully selected patients of advanced age. Although robotic surgery and ventral mesh rectopexy may not be accessible to all patients and surgeons, this represents a single surgeon's practice bias. This study reinforces the importance of perineal procedures for higher-risk individuals.
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Ultrasound improves the outcomes of cardiopulmonary resuscitation in rats by stimulating the cholinergic anti?inflammatory pathway.
Mol Med Rep2019 Jul;():. doi: 10.3892/mmr.2019.10527.
Zhang Yuhan, Song Yue, Shu Tingting, Liang Licai, Shao Weijing, Guo Lang, Sun Peng,
Abstract
The present study investigated the effects of the ultrasound (US), a noninvasive technique, on ischemia?reperfusion injury (IRI) following cardiopulmonary resuscitation (CPR). The animals used in the present study were randomized into five groups (n=8 per group) as follows: i) The CPR group, where the rats underwent 6 min of untreated ventricular fibrillation (VF) followed by CPR and defibrillation; ii) the US group, in which the treatment was identical to the CPR group with the exception that rats were exposed to US treatment 24 h prior to CPR; iii) the MLA group, in which the treatment was identical to the US group with the exception that the ?7 nicotinic acetylcholine receptor (?7nAChR) antagonist MLA (4 mg/kg) was administered 30 min prior to US and VF respectively; iv) the GTS group, in which the treatment was identical to the CPR group with the exception that the ?7nAChR agonist GTS?21 (4 mg/kg) was injected 30 min prior to VF; and v) the SHAM group, in which the rats were exposed to surgical preparation without CPR and US application. At 1 day prior to CPR, the US treatment was administered to the left kidney by US pulses (contrast general mode with 9 MHz) with a bursting mechanical index of 0.72 for 2 min. Following treatment of the left kidney, the right kidney was exposed to identical US treatment for an additional 2 min. The results demonstrated that US preconditioning decreased the number of defibrillations required and shortened the duration of CPR. US also suppressed tumor necrosis factor?? and interleukin?6 levels following resuscitation (P<0.05), and a significantly longer overall survival time was observed in the US?treated animals (P<0.01). In addition, US attenuated neuronal injury and promoted the expression of ?7nAChR in hippocampal neurons (P<0.05). However, the protective effects of US were abolished by MLA and imitated by GTS?21. The results of the present study demonstrated that prior exposure to US may improve animal outcomes following CPR, and the protective effects of US may be dependent on the cholinergic anti?inflammatory pathway (CAP) via ?7nAChR.
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Impact of Perioperative Levosimendan Administration on Risk of Bleeding After Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials.
Am J Cardiovasc Drugs2019 Sep;():. doi: 10.1007/s40256-019-00372-2.
Yan Sen-Bo, Wang Xiao-Yan, Shang Guo-Kai, Wang Zhi-Hao, Deng Qi-Ming, Song Jia-Wen, Sai Wen-Wen, Song Ming, Zhong Ming, Zhang Wei,
Abstract
BACKGROUND:
Levosimendan, a calcium sensitizer and potassium channel opener, has been demonstrated to improve myocardial function without increasing oxygen consumption and to show protective effects in other organs. Recently, a prospective, randomized controlled trial (RCT) revealed an association between levosimendan use and a possible increased risk of bleeding postoperatively. Levosimendan's anti-platelet effects have been shown in in vitro studies. Current studies do not provide sufficient data to support a relation between perioperative levosimendan administration and increased bleeding risk.
PURPOSE:
Our goal was to investigate the relation between perioperative levosimendan administration and increased bleeding risk using a meta-analysis study design.
METHODS:
The PubMed, Ovid, EMBASE and Cochrane Library databases were searched for relevant RCTs before July 1, 2019. The outcome parameters included reoperation secondary to increased bleeding in the postoperative period, the amount of postoperative recorded blood loss, and the need for transfusion of packed red blood cells (RBCs) and other blood products.
RESULTS:
A total of 1160 patients in nine RCTs (576 in the levosimendan group and 584 in the control group) were included according to our inclusion criteria. Analysis showed that perioperative levosimendan administration neither increased the rate of reoperation secondary to bleeding nor increased the amount of postoperative chest tube drainage when compared with the control group. In terms of blood product transfusion, levosimendan did not influence the requirement for RBC transfusion, platelet transfusion nor fresh frozen plasma (FFP) transfusion. Levosimendan also did not shorten or prolong the aortic cross-clamp time or the cardiopulmonary bypass time.
CONCLUSION:
The analyzed parameters, including reoperations due to bleeding, postoperative chest drainage and the requirement for blood products, revealed that levosimendan did not increase postoperative bleeding risk. More studies with a larger sample size are needed to address a more reliable conclusion due to study limitations.
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Correlations between change in neural respiratory drive and heart rate variability in patients submitted to open-heart surgery.
J Exerc Rehabil2019 Aug;15(4):616-621. doi: 10.12965/jer.1938230.115.
Jinakote Metee, Pongpanit Karan,
Abstract
Respiratory muscle dysfunction after open-heart surgery may influence the cardiopulmonary interactions. The purpose of this study was to examine the correlation between change in the neural respiratory drive (NRD) and change in heart rate variability (HRV) in patients submitted to open-heart surgery. An observational cross-sectional study was conducted among 32 participants. NRD was assessed via a surface electromyogram of the parasternal intercostal muscle (sEMGpara). Polar heart rate monitor was used to measure HRV during the deep breathing maneuver. Evaluations were performed on the day of admission and discharge. There were statistically significant differences in NRD and HRV indices between admission and discharge periods (<0.05). The difference in peak root mean square of sEMGpara recorded during resting (?RMS sEMGpara tidal), during maximal inspiratory maneuver (?sEMGpara max), and its normalized values (?RMS sEMGpara%max) were significantly correlated with the difference in total power (?Total power), mean of heart rate (?MeanHR), and mean of R to R intervals (?MeanRR) (=-0.844, =0.004, =-0.835, =0.005, and =0.643, =0.043, respectively). It can be concluded that NRD correlated well with HRV in patients who had undergone open-heart surgery.
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The effect of cardiac rehabilitation at 4 weeks postoperatively on quality of life in patients treated with totally thoracoscopic ablation.
J Exerc Rehabil2019 Aug;15(4):610-615. doi: 10.12965/jer.1938340.170.
Seo Yong-Gon, Sung Jidong, Shin Mal-Soon, Park Yun-Jin, Min Kyoung-Bin, Kang Gyu-Min, Lee Jong-Min, Kim Myung-Ki,
Abstract
There is a lack of evidence on the effect of exercise-based cardiac rehabilitation (EBCR) in patients treated with total thoracoscopic ablation (TTA) for atrial fibrillation (AF). Our study investigated the efficacy and safety of postoperative exercise intervention in patients recovering from TTA. Twenty-four patients participated in the study, and were divided into the two groups, exercise group (EG) (n=12) and control group (n= 12). Patients in EG performed the exercise intervention including the aerobic and resistance exercise program twice a week for 8 weeks, which was used as a hospital-based cardiac rehabilitation for the out-patient. A cardiopulmonary exercise test was administered to evaluate aerobic exercise capacity, and qualitative aspect of patient's life was assessed using the Short Form 36 questionnaires to compare pre and postoperative wellness of patient's life. Although there was an increase of VO (peak oxygen uptake) after exercise intervention, no significant improvement was found (=0.055). Two of 4 physical health scores (role-physical, =0.013 and general health, =0.05) and three of four mental health scores (vitality, =0.027, social function, =0.016, and mental health, =0.003) were significantly improved after 8 weeks of EBCR. Each summarized scale in the physical (=0.022) and mental (= 0.004) survey section was also significantly improved in postoperative assessment compared to the preoperative one. In this context, we concluded that EBCR initiated at the time point of 4th week after TTA operation can guarantee the secure postoperative physical activity, and the 8 weeks of EBCR can effectively improve the quality of life in AF Patients.
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Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Template for In-Hospital Cardiac Arrest: A Consensus Report From a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia).
Circulation2019 Sep;():CIR0000000000000710. doi: 10.1161/CIR.0000000000000710.
Nolan Jerry P, Berg Robert A, Andersen Lars W, Bhanji Farhan, Chan Paul S, Donnino Michael W, Lim Swee Han, Ma Matthew Huei-Ming, Nadkarni Vinay M, Starks Monique A, Perkins Gavin D, Morley Peter T, Soar Jasmeet, ,
Abstract
Utstein-style reporting templates provide a structured framework with which to compare systems of care for cardiac arrest. The 2004 Utstein reporting template encompassed both out-of-hospital and in-hospital cardiac arrest. A 2015 update of the Utstein template focused on out-of-hospital cardiac arrest, which makes this update of the in-hospital template timely. Representatives of the International Liaison Committee on Resuscitation developed an updated in-hospital Utstein reporting template iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018. Data elements were grouped by hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. Elements were classified as core or supplemental by use of a modified Delphi process. Variables were described as core if they were considered essential. Core variables should enable reasonable comparisons between systems and are considered essential for quality improvement programs. Together with core variables, supplementary variables are considered useful for research.
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Perioperative considerations in the management of obstructive sleep apnoea.
Med J Aust2019 Sep;():. doi: 10.5694/mja2.50326.
Holt Nicolette R, Downey Glenn, Naughton Matthew T,
Abstract
Obstructive sleep apnoea (OSA) is characterised by repetitive compromise of the upper airway, causing impaired ventilation, sleep fragmentation, and daytime functional impairment. It is a heterogeneous condition encompassing different phenotypes. The prevalence of OSA among patients presenting for elective surgery is growing, largely attributable to an increase in age and obesity rates, and most patients remain undiagnosed and untreated at the time of surgery. This condition is an established risk factor for increased perioperative cardiopulmonary morbidity, heightened in the presence of concurrent medical comorbidities. Therefore, it is important to perform preoperative OSA screening and risk stratification - using the STOP-Bang screening questionnaire, nocturnal oximetry, and ambulatory and in-laboratory polysomnography, for example. Postoperative risk assessment is an evolving process that encompasses evaluation of upper airway compromise, ventilatory control instability, and pain-sedation mismatch. Optimal postoperative OSA management comprises continuation of regular positive airway pressure, a multimodal opioid-sparing analgesia strategy to limit respiratory depression, avoidance of supine position, and cautious intravenous fluid administration. Supplemental oxygen does not replace a patient's regular positive airway pressure therapy and should be administered cautiously to avoid risk of hypoventilation and worsening of hypercapnia. Continuous pulse oximetry monitoring with specified targets of peripheral oxygen saturation measured by pulse oximetry is encouraged.
© 2019 AMPCo Pty Ltd.
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Roles of TGF?1 in the expression of phosphoinositide 3-kinase isoform genes and sensitivity and response of lung telocytes to PI3K inhibitors.
Cell Biol Toxicol2019 Sep;():. doi: 10.1007/s10565-019-09487-3.
Song Dongli, Tang Li, Wang Lu, Huang Jianan, Zeng Tao, Fang Hao, Wang Xiangdong,
Abstract
BACKGROUND:
The mouse lung telocyte cell line (TC) recently established provides further opportunities to learn TC biology and functions. The present study aims at investigating regulatory roles of phosphoinositide 3-kinase (PI3K) isoforms in TC proliferation and movement and in TGF?1-induced sensitivity and response of lung TCs to PI3K inhibitors.
MATERIALS AND METHODS:
Network and molecular interactions of genes coding PI3K family or TGF? family proteins in mouse primary TCs were defined. Mouse lung TC proliferation, apoptosis, cell cycle, and dynamical bio-behaviors were measured with or without TGF?1 stimulation or PI3K catalytic isoform protein (PI3K/mTOR, PI3K?/?/?, PI3K p110?, or pan-PI3K) inhibitions.
RESULTS:
The present study showed the difference of network characteristics and interactions of genes coding PI3K isoform proteins or TGF? family proteins in primary lung telocytes from mouse lungs compared to those of other cells residing in the lung. TGF?1 had diverse effects on TC proliferation with altered TC number in G2 or S phase, independent upon the administered dose of TGF?1. PI3K?/?/?, PI3K/mTOR, and PI3K p110? were involved in TC proliferation, of which PI3K?/?/? was more sensitive. The effects of pan-PI3K inhibitor indicate that more PI3K isoforms were stimulated by the administering of external TGF?1 and contributed to TGF?1-induced TC proliferation. PI3K p110? upregulated TC proliferation and movement dynamically without TGF?1, and downregulated TC proliferation with TGF?1 stimulation, but not TC movement. PI3K?/?/? and PI3K/mTOR were more active in TGF?1-induced S phase accumulation and had similar dynamic effects to PI3K p110?. Gene expression of PI3K isoforms in TCs was upregulated after TGF?1 stimulation. The expression of PIK3CA coding p110-? or PIK3CG coding p110-? were up- or downregulated in TCs without TGF?1, respectively, when PI3K/mTOR, PI3K?/?/?, PI3K p110?, or pan-PI3K were inhibited. TGF?1 upregulated the expression of PIK3CA and PIK3CB, while downregulated the expression of PIK3CD and PIK3CG.
CONCLUSION:
Our data imply that TGF?1 plays divergent roles in the expression of PI3K isoform genes in lung TCs and can alter the sensitivity and response of lung TCs to PI3K inhibitors.
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Effects of lung deflation induced by tiotropium/olodaterol on the cardiocirculatory responses to exertion in COPD.
Respir Med2019 Sep;157():59-68. doi: S0954-6111(19)30286-0.
Berton Danilo C, Marques Renata D, Palmer Brandon, O'Donnell Denis E, Neder J Alberto,
Abstract
BACKGROUND:
Hyperinflation has been associated with negative cardiocirculatory consequences in patients with chronic obstructive pulmonary disease (COPD). These abnormalities are likely to worsen when the demands for O increase, e.g., under the stress of exercise. Thus, pharmacologically-induced lung deflation may improve cardiopulmonary interactions and exertional cardiac output leading to higher limb muscle blood flow and oxygenation in hyperinflated patients with COPD.
METHODS:
20 patients (residual volume?=?201.6?±?63.6% predicted) performed endurance cardiopulmonary exercise tests (75% peak) 1?h after placebo or tiotropium/olodaterol 5/5??g via the Respimat® inhaler (Boehringer Ingelheim, Ingelheim am Rhein, Germany). Cardiac output was assessed by signal-morphology impedance cardiography. Near-infrared spectroscopy determined quadriceps blood flow (indocyanine green dye) and intra-muscular oxygenation.
RESULTS:
Tiotropium/olodaterol was associated with marked lung deflation (p?
CONCLUSIONS:
The beneficial effects of tiotropium/olodaterol on resting and operating lung volumes are not translated into enhanced cardiocirculatory responses to exertion in hyperinflated patients with COPD. Improvement in exercise tolerance after dual bronchodilation is unlikely to be mechanistically linked to higher muscle blood flow and/or O delivery.
Copyright © 2019. Published by Elsevier Ltd.
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Cardiac arrest in the intensive care unit: An assessment of preventability.
Resuscitation2019 Sep;():. doi: S0300-9572(19)30607-0.
Moskowitz Ari, Berg Katherine M, Cocchi Michael N, Chase Maureen, Yang Jesse, Sarge Jennifer, Grossestreuer Anne, Sarge Todd, O' Donoghue Sharon, Donnino Michael W,
Abstract
AIM:
Cardiac arrest in the intensive care unit (ICU-CA) is a common and highly morbid event. We investigated the preventability of ICU-CAs and identified targets for future intervention.
METHODS:
This was a prospective, observational study of ICU-CAs at a tertiary care center in the United States. For each arrest, the clinical team was surveyed regarding arrest preventability. An expert, multi-disciplinary team of physicians and nurses also reviewed each arrest. Arrests were scored 0 (not at all preventable) to 5 (completely preventable). Arrests were considered 'unlikely but potentially preventable' or 'potentially preventable' if at least 50% of reviewers assigned a score of ?1 or ?3 respectively. Themes of preventability were assessed for each arrest.
RESULTS:
43 patients experienced an ICU-CA and were included. A total of 14 (32.6%) and 13 (30.2%) arrests were identified as unlikely but potentially preventable by the expert panel and survey respondents respectively, and an additional 11 (25.6%) and 10 (23.3%) arrests were identified as potentially preventable. Timing of response to clinical deterioration, missed/incorrect diagnosis, timing of acidemia correction, timing of escalation to a more senior clinician, and timing of intubation were the most commonly cited contributors to potential preventability. Additional themes identified included the administration of anxiolytics/narcotics for agitation later identified to be due to clinical deterioration and misalignment between team and patient/family perceptions of prognosis and goals-of-care.
CONCLUSIONS:
ICU-CAs may have preventable elements. Themes of preventability were identified and addressing these themes through data-driven quality improvement initiatives could potentially reduce CA incidence in critically-ill patients.
Copyright © 2019. Published by Elsevier B.V.
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Biodegradable reduction-responsive polymeric micelles for enhanced delivery of melphalan to retinoblastoma cells.
Int J Biol Macromol2019 Sep;():. doi: S0141-8130(19)34554-4.
Li Jia, Wang Jihong, Zhang Xuetong, Xia Xin, Zhang Chenchen,
Abstract
Melphalan (MEL) is an effective chemotherapeutic agent for treatment of retinoblastoma (Rb) which is the most common childhood malignancy. However, the inherent cardiopulmonary toxicity and hazardous integration limit its therapeutic effect on RB. N-Acetylheparosan (AH), a natural heparin-like polysaccharide in mammals with long circulation effect and good biocompatibility, was linked by d-?-tocopherol acid succinate (VES) via and cystamine (CYS) to synthesize reduction-responsive N-acetylheparosan-CYS-Vitamin E succinate (AHV) copolymers. In addition, CYS was replaced by adipic acid dihydrazide (ADH) to obtain a control of non-reduction-responsive polymers N-acetylheparosan-ADH-Vitamin E succinate (ADV). MEL-loaded AHV micelles (MEL/AHV) as well as ADV micelles (MEL/ADV) were prepared with small particle size and high drug loading content. In vitro drug release showed that MEL/AHV micelles presented obvious reduction-triggered release behavior compared with MEL/ADV. In vitro antitumor effects were investigated using WERI-Rb-1 retinoblastoma cells. Cytotoxicity experiments showed that the IC of MEL/AHV was significantly lower than that of free MEL and MEL/ADV, suggesting that MEL/AHV enhanced the cytotoxicity against retinoblastoma cells. Furthermore, MEL/AHV micelles were more easily uptaken by multiple pathways compared with MEL/ADV and free MEL. Therefore, MEL/AHV might be a potential delivery system for enhanced delivery of melphalan to Rb cells.
Copyright © 2019. Published by Elsevier B.V.
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Role of Bivalirudin for Anticoagulation in Adult Perioperative Cardiothoracic Practice.
J Cardiothorac Vasc Anesth2019 Aug;():. doi: S1053-0770(19)30887-0.
Erdoes Gabor, Ortmann Erik, Martinez Lopez De Arroyabe Blanca, Reid Catherine, Koster Andreas,
Abstract
Bivalirudin, a direct thrombin inhibitor with a fast onset of action and short half-life, is often referred to as an alternative anticoagulant to a heparin/protamine regimen. Bivalirudin demonstrated promising results as an anticoagulant in cardiac surgery with and without cardiopulmonary bypass, postcardiotomy extracorporeal membrane oxygenation, interventional cardiology and endovascular procedures, and particularly in the treatment of patients with heparin-induced thrombocytopenia undergoing high-risk cardiac surgery. Currently, bivalirudin in cardiac surgery with cardiopulmonary bypass has a limited clinical spectrum, likely because the still obvious advantages of its competitor, heparin, outweigh it in terms of medical costs, established point-of-care monitoring systems, and availability of protamine as a reversal agent. The unique pharmacology of the drug also requires adjustment of surgical and perfusion strategy. In contrast, in off-pump coronary artery surgery, established protocols from interventional cardiology can be easily translated into the operating room. In this setting bivalirudin has the potential for a more important role in the future. Through a triple mechanism of action-inhibition of plasma thrombin, clot bound thrombin, and collagen-induced platelet activation-bivalirudin may perform better than heparin by attenuating the immediate postoperative prothrombotic state and thus positively impacting the early coronary graft patency after off-pump coronary artery bypass grafting. Further studies are necessary to better evaluate this niche field and discover further applications for this unique anticoagulant.
Copyright © 2019 Elsevier Inc. All rights reserved.
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Calcium/Calmodulin-Dependent Kinase (CaMKII) Inhibition Protects Against Purkinje Cell Damage Following CA/CPR in Mice.
Mol Neurobiol2019 Sep;():. doi: 10.1007/s12035-019-01765-9.
Chalmers Nicholas E, Yonchek Joan, Steklac Kathryn E, Ramsey Matthew, Bayer K Ulrich, Herson Paco S, Quillinan Nidia,
Abstract
Ischemic brain damage is triggered by glutamate excitotoxicity resulting in neuronal cell death. Previous research has demonstrated that N-methly-D-aspartate (NMDA) receptor activation triggers downstream calcium-dependent signaling pathways, specifically Ca/calmodulin-dependent protein kinase II (CaMKII). Inhibiting CaMKII is protective against hippocampal ischemic injury, but there is little known about its role in the cerebellum. To examine the neuroprotective potential of CaMKII inhibition in Purkinje cells, we subjected C57BL/6 or CaMKII? KO male mice (8-12 weeks old) to cardiac arrest followed by cardiopulmonary resuscitation (CA/CPR). We performed a dose-response study for tat-CN19 and cerebellar injury was analyzed at 7 days after CA/CPR. Acute signaling was assessed at 6 h after CA/CPR using Western blot analysis. We observed increased phosphorylation of the T286 residue of CaMKII, suggesting increased autonomous activation. Analysis of Purkinje cell density revealed a decrease in cell density at 7 days after CA/CPR that was prevented with tat-CN19 at doses of 0.1 and 1 mg/kg. However, neuroprotection in the cerebellum required doses that were 10-fold higher than what was needed in the hippocampus. CaMKII? KO mice subjected to sham surgery or CA/CPR had similar Purkinje cell densities, suggesting CaMKII? is required for CA/CPR-induced injury in the cerebellum. We also observed a CA/CPR-induced activation of death-associated protein kinase (DAPK1) that tat-CN19 did not block. In summary, our findings indicate that inhibition of autonomous CaMKII activity is a promising therapeutic approach that is effective across multiple brain regions.
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Quality of life after in-hospital cardiopulmonary resuscitation for patients over the age of 80 years.
Postgrad Med J2019 Sep;():. doi: postgradmedj-2019-136565.
Burden Eleanor, Pollock Lucy, Paget Camilla,
Abstract
OBJECTIVES:
Success of in-hospital resuscitation decreases with age; however, national data show that 11.3% of patients over 80 years survive to discharge. There are few published qualitative data about the quality of life for these patients postsuccessful resuscitation. We aimed to investigate postresuscitation quality of life in patients over the age of 80 through a series of case studies.
METHODS:
All patients over the age of 80 years, who received cardiopulmonary resuscitation (CPR) at our district general hospital in 2015-2016, were included. Success of resuscitation, survival at day 1 and to discharge were recorded. For patients who survived to 1 day and beyond, case reports were written to create individual patient stories.
RESULTS:
47 patients over the age of 80 years received CPR at Musgrove Park Hospital over a 2-year period. Five (10.6%) survived to discharge. Of those surviving to discharge, two had substantial functional decline, requiring discharge to nursing homes having previously been independent. Of the five families/patients who commented on their experience, only one expressed a positive view. When discussed, the majority of patients/families opted for a Do Not Attempt CPR.
CONCLUSION:
Our results have shown that there is a risk of substantial functional decline associated with successful CPR in those patients over the age of 80 years. The majority of patients and relatives contacted after successful resuscitation expressed a negative view of the experience. Our study highlights the importance of having early informed discussions with patients and families about CPR in order to avoid detrimental outcomes and ensure patient wishes are correctly represented.
© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.
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Propensity and impact of autologous platelet rich plasma use in acute type A dissection.
J Thorac Cardiovasc Surg2019 Jun;():. doi: S0022-5223(19)31205-X.
Sandhu Harleen K, Tanaka Akiko, Dahotre Shruti, Charlton-Ouw Kristofer M, Miller Charles C, Estrera Anthony L, Sheinbaum Roy, Safi Hazim J, Zhou Shao-Feng,
Abstract
BACKGROUND:
Coagulopathy in patients undergoing open repair of acute type A aortic dissection using cardiopulmonary bypass and hypothermic circulatory arrest is a common complication. Autologous platelet rich plasma is an intraoperative blood conservation technique, which has been shown in previous studies to promote hemostasis, leading to a reduction of blood product transfusions during elective aortic surgery. The purpose of this study is to evaluate the effectiveness of autologous platelet rich plasma as a blood conservation technique during open surgical repair of acute type A aortic dissection.
METHODS:
We reviewed all acute type A aortic dissection cases using hypothermic circulatory arrest, excluding patients presenting in extremis. Perioperative transfusion requirements and clinical outcomes were analyzed. The end points analyzed included early mortality, postoperative stroke, renal dysfunction, prolonged ventilation, coagulopathy, and length of postoperative intensive care unit stay. Parsimonious and saturated propensity scores were calculated for platelet rich plasma use, and all outcomes were propensity adjusted.
RESULTS:
Between 2003 and 2014, 85 of 391 acute type A aortic dissection repairs used autologous platelet rich plasma. Mean age of patients was 58 ± 15 years, and 70% were male. Obstructive sleep apnea (22% vs 13%, P = .04) and baseline ejection fraction (57% ± 6.7% vs 55% ± 10%; P = .014) were higher in the autologous platelet rich plasma group. Intraoperative propensity-adjusted blood products, 2 units fewer packed red blood cells (P = .001), 4 units fewer fresh-frozen plasma (P = .001), 6 units fewer platelets (P = .001), 1.3 units fewer cell-savers (P = .002), and 5 units fewer cryoprecipitate (P = .001) were significantly reduced by autologous platelet rich plasma use. Significant unadjusted reduction in postoperative reoperation for bleeding (8% vs 17%, P = .046) after autologous platelet rich plasma was reported, although propensity adjustment eliminated significance (P = .079). No difference in stroke, cardiac, or renal complications was observed. Postoperative transfusion needed during the first 3 days was significantly reduced in the autologous platelet rich plasma group: 2 units fewer packed red blood cells (P = .13), 2 units fewer fresh-frozen plasma (P = .018), and 5 units fewer platelets (P = .001), when compared with those without autologous platelet rich plasma. Ventilation time was reduced by 3 days (P = .002), and intensive care length of stay was reduced by 3 days (P = .063) after intraoperative autologous platelet rich plasma use.
CONCLUSIONS:
The use of autologous platelet rich plasma in patients undergoing open repair of acute type A aortic dissection was associated with a reduction in intraoperative and postoperative blood transfusions, as well as decreased early postoperative morbidity.
Copyright © 2019. Published by Elsevier Inc.
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Association of fragmented QRS with left atrial scarring in patients with persistent atrial fibrillation undergoing radiofrequency catheter ablation.
Heart Rhythm2019 Sep;():. doi: S1547-5271(19)30831-8.
Canpolat Ugur, Mohanty Sanghamitra, Trivedi Chintan, Chen Qiong, Ayhan Huseyin, Gianni Carola, Della Rocca Domenico G, MacDonald Bryan, Burkhardt J David, Bassiouny Mohammed, Gallinghouse G Joseph, Al-Ahmad Amin, Horton Rodney, Di Biase Luigi, Natale Andrea,
Abstract
BACKGROUND:
Fragmented QRS (fQRS) in 12-lead ECG is a non-invasive marker of intra-myocardial conduction delay due to ventricular scarring which has not been studied in AF before.
OBJECTIVE:
To assess the association of fQRS with left atrial (LA) scarring in patients with persistent AF (PsAF) undergoing first catheter ablation.
METHODS:
A total of 376 patients with PsAF were enrolled. Severity of LA scarring was assessed using electroanatomic mapping. Narrow fQRS was defined by the presence of an additional R wave (R') or notching in the nadir of the S wave, or presence of >1 R' in two contiguous leads corresponding to inferior, lateral, or anterior myocardial regions.
RESULTS:
Both, any degree (97.3% vs 63.3%) and severe (42.2% vs 6.3%) LA scarring were higher in patients with fQRS. Age and fQRS were found as independent predictors of severe LA scarring. At multiple ventricular regions, fQRS had a diagnostic accuracy of 79.8% for prediction of severe LA scarring. Non-PV triggers were more often detected and ablated in patients with fQRS and severe LA scarring (84.4% vs. 70%, p=0.001). ATa recurrence was observed in 131 (34.8%) patients during 18.9 ± 7.7 months follow-up which was significantly higher in patients with fQRS (53.2% vs 16.8%). In the multi-variate analysis, fQRS was found to be a significant predictor of recurrence [HR:4.65 (2.91-7.42), p-value <0.001].
CONCLUSION:
Our study results showed that as a simple, available and non-invasive marker, fQRS at multiple ventricular regions was significantly associated with the severity of LA scarring in persistent AF patients.
Copyright © 2019. Published by Elsevier Inc.
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Selective use of inpatient interstage management after Norwood procedure.
Ann Thorac Surg2019 Sep;():. doi: S0003-4975(19)31351-7.
Hill Garick D, Tanem Jena, Ghanayem Nancy, Rudd Nancy, Ollberding Nicholas J, Lavoie Julie, Frommelt Michele,
Abstract
BACKGROUND:
We report our intermediate-term results following Norwood procedure, including use of an interstage inpatient management strategy for high-risk patients, and sought to create a predictive model for probability of discharge.
METHODS:
A single-site retrospective review was conducted for all patients undergoing Norwood from 2006-2016 (n=177). We compared those discharged home with those who either remained hospitalized until Glenn or died prior to Norwood discharge. Multivariable logistic regression was used to develop a predictive model for discharge.
RESULTS:
During the study period, 120(68%) patients were discharged home, 45(25%) remained hospitalized and 12(7%) died before Glenn (median age: 71 days). Interstage survival for those discharged after Norwood was 100%. Longitudinal survival for the cohort was 86%, 81% and 77% at 1, 5, and 10 years. Ten year survival was significantly greater for the discharged group compared to the interstage inpatients (86% vs. 56%, p<0.0001). A reduced predictive model of discharge included lower gestational age (OR=0.95), lower median income for zip code (OR=0.4), lower birth weight-for-age z-score (OR=0.56), longer cardiopulmonary bypass time (OR=0.45), and BT shunt (OR=0.32).
CONCLUSIONS:
Survival up to 10 years after Norwood procedure is good using a strategy of inpatient care for a subset of high-risk patients to mitigate home interstage mortality. A probabilistic model used after Norwood was able to predict interstage discharge with good accuracy, but will require external validation to ensure generalizability. Further work is also needed to determine optimal palliative pathways for the high-risk patients due to the notable attrition beyond successful bidirectional Glenn.
Copyright © 2019. Published by Elsevier Inc.
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Within-Subject Performance on a Real-Life, Complex Task and Traditional Lab Experiments: Measures of Word Learning, Raven Matrices, Tapping, and CPR.
J Cogn2019 May;2(1):12. doi: 10.5334/joc.65.
Sense Florian, Maaß Sarah, Gluck Kevin, van Rijn Hedderik,
Abstract
In this data report, we describe a three-session experiment spanning six months. Several well-controlled laboratory tasks (Word Learning, Raven Matrices, and Tapping) and Cardiopulmonary Resuscitation (CPR), a complex but well-defined real-world task, were administered. Data are reported from 50 participants for the first session, 40 for the second, and 34 for the third. CPR is a useful domain for studying real-world performance inside the laboratory because clear performance standards can be applied to quantifying learners' proficiency covering both the first steps that need to be taken prior to the initiation of CPR (declarative knowledge) as well as the compressions and ventilations themselves (procedural skill). This research resulted in a rich dataset with a range of different measures for all participants. For all tasks, the complete set of raw data are made available along with relevant aggregate performance scores (see https://osf.io/m8bxe/). The raw data in particular will enable other researchers to explore potential analyses and modeling beyond the scope of our own. The details of the data collection protocol and available data are documented here to facilitate this process.
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Talimogene laherparepvec induces durable response of regionally advanced Merkel cell carcinoma in 4 consecutive patients.
JAAD Case Rep2019 Sep;5(9):782-786. doi: 10.1016/j.jdcr.2019.06.034.
Westbrook Brian C, Norwood T Graham, Terry Nina L J, McKee Svetlana B, Conry Robert M,
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Myxedema coma accompanied by sick sinus syndrome and hypoventilation: A case report.
J Gen Fam Med2019 Sep;20(5):206-208. doi: 10.1002/jgf2.267.
Harada Ko, Murakami Shuntaro, Tokumasu Kazuki, Togawa Yu, Otsuka Fumio,
Abstract
Myxedema coma is an emergency presentation of hypothyroidism, and cardiopulmonary manifestations of the disease are related to a high mortality rate. We herein report a case of myxedema coma accompanied by sick sinus syndrome requiring temporary cardiac pacing and hypercapnic respiratory failure in an 87-year-old woman. This case is unique because both of the cardiac and pulmonary manifestations were reversible and successfully treated with thyroid hormone replacement. Our case indicates that early detection of the condition and administration of levothyroxine are essential to improve the life-threatening condition and avoid invasive treatment such as permanent pacemaker implantation or intubation.
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