Preoperative anaemia management in patients undergoing vascular surgery

CAVIAR is a multicentre prospective stepped observational study encompassing 160 patients undergoing vascular intervention. The aim was to identify whether it was feasible to establish a preoperative anaemia pathway and, if so, the efficacy of intravenous iron for treatment of preoperative anaemia. Large barriers prevented implementation of an intravenous iron pathway, with only ten patients receiving intravenous iron and a small increase in haemoglobin level (mean 5·7 (95 per cent c.i. 4·5 to 6·9) g/l). Preoperative anaemia was associated with a longer hospital stay and greater transfusion requirement. Anaemia common and dedicated pathway difficult to instigate.

Management of children and adolescents having type 1 diabetes during COVID-19 pandemic in India: challenges and solutions

Purpose

Type 1 diabetes (T1D) requires a holistic approach and continuous care. The current COVID-19 pandemic has made the health care professionals realise its challenges even more ardently than in the normal times. In a country like India with its huge population burden and a significant number of people having T1D, the risk of COVID-19 in people having T1DM is considerably high.

Methods

In this article, we are sharing our practical experiences of problems faced by children and adolescents having T1DM during the past 2 months of lockdown.

Results

We have classified the challenges into 3 broad categories based on diabetes self-management, healthcare system and psychosocial aspects. We have tried to provide precise, comprehensive and region specific solutions to these challenges. Solutions briefly include maintaining the supply chain of essentials like insulin, syringes and glucose meter strips to psychological support, financial aid and support for hospitalization in case of COVID-19 itself or diabetes complications including diabetic ketoacidosis.

Conclusions

Children and adolescents having T1DM require special care and attention during this period of COVID-19 pandemic because of various challenges as discussed. Our proposed solutions may help them overcome these problems and help them in better diabetes management during such emergency situations.

Local solutions by slum communities to deal with summer water scarcity: Learning from Indore, India

Issue

Government of India's, NITI Aayog reports that 600 million people in India face extreme water stress. Slums and similarly vulnerable urban populations face huge challenges in accessing water for basic needs, increasing in summers. Indore is an extreme water stressed city in India.

Methods

During Urban Health Resource Centre's (UHRC) program work in slums, including women's groups UHRC forms and trains in 2018 we learnt of acute water scarcity in summers. Women in 16 slums were motivated to evolve and implement possible solutions. Most slum dwellers provide services on low wages to the city. With public bore-wells drying-up, in Feb.- May 2019 UHRC helped women's groups' submit community requests, reminders to elected ward representatives and Municipal offices for free water tankers. UHRC motivated slum families to collectively negotiate with private providers to reduce cost, systematise water supply for more families. In 4 peri-urban slums we strengthened water access relationship between farmers and slum dwellers.

Results

During Feb.-May 2019 10 of the 16 slums received free water tankers from Municipal Corporation. More population of 4 peri-urban slums accessed water from farmer's tube-well. Slum families evolved coping mechanisms of storing more general use water in underground tanks or many cans. Families with larger storage shared water with needy families demonstrating social cooperation.

Lessons

Trained and mentored slum women's groups gently negotiating with elected ward-level politicians and municipal officials helps in provision of free water tankers in summers. This strategy to get govt. water supply in slums is adaptable in fast growing Indian cities. Owing to geographical proximity, rural-urban cooperation can help slums in city's fringes obtain water from farmer tube-wells used for irrigation. Fostering community cooperation helps more needy families get water.

Key messages

Slum communities develop local mechanisms to access and store water which need to be understood by civil society organisations and Government to improve solutions for water supply in summer months. Slum women emerge as dynamic actors to improve the lives of both women and men (Sen, 2000). In this case women help negotiate for and foster community cooperation for water, store more water.

Assessing and implementing practical ways to address slum health determinants: Learning from India

Issue

There is a need for adaptable/scalable methods to understand environmental determinants of health and well-being in slums of LMIC cities. Catalysing grassroots actions to reduce health inequalities is needed with strong community leadership in slums.

Methods

Conducted in 2016-2017 in Indore (3 m population), India this practice undertakes qualitative health assessments using simple, actionable indicators with community knowledge and prioritizes solutions. Participatory neighbourhood level assessment of sewerage, toilets, garbage disposal and water supply by slum women was done using three colour scale: red for poor condition, yellow for moderate condition and green for good condition across 24 slums. Since slum women live these challenges daily, they can assess conditions. A qualitative adaptation of WHO's Urban HEART, this practice seeks to learn how slum women assess conditions, implement actions for improvement of slum environment.

Results

Context responsive actions included submitting community petitions and reminders to Municipal authorities by slum women to repair sewerage lines, construct toilets, increase regularity of garbage collection and improve public water supply in slums. Of 24 slums assessed in 2016, 6 were designated as “red”, 14 as “yellow” and 4 as “green” on condition of toilets and sewerage. On garbage disposal and water supply, 8 slums were designated as “red”, 10 as “yellow” and 6 as “green”. With coordination with Municipal authorities in 2017, slums on “red” reduced to 3 in each group, those assessed as “green” increased to 10 with improved conditions.

Lessons

This approach helps slum communities to assess problems and implement solutions. The methodology is simple, low-cost, easily understood by less educated, academics, policy makers and uses community wisdom. It is adaptable for NGOs, relevant policies/guidelines in LMIC cities. This collective community health assessment directly catalyses demand side action.

Key messages

Collective efficacy is a group’s shared belief in its ability to utilize information, pursue actions to overcome obstacles accomplishing a valued goal. This method is key to replicate this practice. People’s efforts to bring public services to the slums through collective action can reduce urban health inequality.

A European consensus statement on the use of four-factor prothrombin complex concentrate for cardiac and non-cardiac surgical patients

Modern four-factor prothrombin complex concentrate was designed originally for rapid targeted replacement of the coagulation factors II, VII, IX and X. Dosing strategies for the approved indication of vitamin K antagonist-related bleeding vary greatly. They include INR and bodyweight-related protocols as well as fixed dose regimens. Particularly in the massively bleeding trauma and cardiac surgery patient, four-factor prothrombin complex concentrate is used increasingly for haemostatic resuscitation. Members of the Transfusion and Haemostasis Subcommittee of the European Association of Cardiothoracic Anaesthesiology performed a systematic literature review on four-factor prothrombin complex concentrate. The available evidence has been summarised for dosing, efficacy, drug safety and monitoring strategies in different scenarios. Whereas there is evidence for the efficacy of four-factor prothrombin concentrate for a variety of bleeding scenarios, convincing safety data are clearly missing. In the massively bleeding patient with coagulopathy, our group recommends the administration of an initial bolus of 25 IU.kg^-1 . This applies for: the acute reversal of vitamin K antagonist therapy; haemostatic resuscitation, particularly in trauma; and the reversal of direct oral anticoagulants when no specific antidote is available. In patients with a high risk for thromboembolic complications, e.g. cardiac surgery, the administration of an initial half-dose bolus (12.5 IU.kg^-1 ) should be considered. A second bolus may be indicated if coagulopathy and microvascular bleeding persists and other reasons for bleeding are largely ruled out. Tissue-factor-activated, factor VII-dependent and heparin insensitive point-of-care tests may be used for peri-operative monitoring and guiding of prothrombin complex concentrate therapy.

Post-traumatic preauricular pulsatile swelling in a patient on oral anticoagulation therapy

The differential diagnoses for preauricular swellings include dermoid cyst, lymph nodes, lipoma, nerve sheath tumours, parotid swelling, mastoiditis, vascular malformations and arterio-venous fistulas aneurysms/pseudoaneurysms. Superficial temporal artery pseudoaneurysm(s) (STAPA) are rare (1% of all aneurysms) vascular complications, which occur following a blunt injury of the head or iatrogenic causes. The use of anticoagulation therapy increases the risk of pseudoaneurysm formation. We present a case of traumatic STAPA while on oral anticoagulation. He was treated with surgical exploration, STAPA excision with ligation of the vessel. He had an uneventful recovery with a good functional and cosmetic outcome at 1 year.

A new mechanism for void-cascade interaction from nondestructive depth-resolved atomic-scale measurements of ion irradiation-induced defects in Fe

The nondestructive investigation of single vacancies and vacancy clusters in ion-irradiated samples requires a depth-resolved probe with atomic sensitivity to defects. The recent development of short-pulsed positron beams provides such a probe. Here, we combine depth-resolved Doppler broadening and positron annihilation lifetime spectroscopies to identify vacancy clusters in ion-irradiated Fe and measure their density as a function of depth. Despite large concentrations of dislocations and voids in the pristine samples, positron annihilation measurements uncovered the structure of vacancy clusters and the change in their size and density with irradiation dose. When combined with transmission electron microscopy measurements, the study demonstrates an association between the increase in the density of small vacancy clusters with irradiation and a remarkable reduction in the size of large voids. This, previously unknown, mechanism for the interaction of cascade damage with voids in ion-irradiated materials is a consequence of the high porosity of the initial microstructure.

P1000Aetiology and efficacy of atrial fibrillation ablation in young adults

Introduction

Little is known regarding the aetiology or outcome of atrial fibrillation (AF) occurring in young adults. This retrospective analysis was performed to explore the demographics and efficacy of AF ablation in this population.

Methods

Patients were included who had undergone ≥1 AF ablation under the age of 40 between 2006-2018. Recurrence was defined as return of either documented AF or previous symptoms for >30s following a 3-month blanking period. Initial exploratory co-variates were included in a univariate analysis and those terms with P-value of <0.1 were then used to generate a Cox proportional-hazards multivariate model.

Results

124 patients (33.6 ± 4.7 yrs, 77% men), initially presenting with paroxysmal AF (pAF; n = 97) or persistent AF (n = 27), underwent 175 AF ablation procedures. 22.6% (n = 28) also had atrial flutter. Time from symptom onset to first ablation was 50.7 ± 46.2 months. Relevant cardiovascular-related demographics were analysed: hypertension in 8.9% (n = 11); diabetes in 1.6% (n = 2); positive family history of AF in 12.9% (n = 16); and family history of sudden cardiac death in 2.4% (n = 3). Mean CHA2DS2-VASc score was 0.35. Of those patients with documented echocardiogram imaging (n = 91), 26.4% (n = 24) had LA dilatation and 6.6% (n = 6) had LV dysfunction. Patients with LA dilatation underwent more ablations (2.3 ± 0.3) compared to controls (1.5 ± 0.1; p < 0.001).

Ablation strategy was pulmonary vein isolation (PVI) only in 67.2% (n = 119), with additional ablation in the remaining: roof line in 18.9% (n = 33); cavotricuspid isthmus line in 13.1% (n = 23); mitral isthmus line in 2.3% (n = 4); superior vena cava isolation in 2.3% (n = 4); complex fractionated atrial electrograms in 14.9% (n = 26). Mean procedure time was 155 ± 41 min, mean ablation time was 1657 ± 991 s and mean fluoroscopy time was 32.6 ± 23.4 min. General anaesthesia was used in 43.4% (n = 76). Complications included femoral haematoma (n = 2), tamponade (n = 1) and pulmonary vein stenosis (n = 2).

90 days of follow-up was available for 137 procedures performed for pAF (n = 105) and persistent AF (n = 32). For pAF, overall recurrence was 61.9% for first ablations and 62.9% overall. Recurrence was 56.3% for persistent AF.

Factors significantly associated with increased AF recurrence in univariate analysis were

male gender (hazard ratio (HR) 2.3, 95% confidence interval (CI): 1.2-4.4, p = 0.011), hypertension (HR 0.5, CI: 0.2-1.1, p = 0.067), family history of sudden cardiac death (HR 6.8, CI: 1.6-29.0 , p = 0.010) and enlarged LA size (HR 2.2, CI: 1.3-3.6, p = 0.003). In multivariate analysis, the only significant predictor of poor outcome was enlarged LA size (HR 2.0, 95% CI: 1.2-3.5, p = 0.011).

Conclusions

Young patients with AF may have structurally abnormal hearts, and therefore do not only present with lone AF. LA size may be used as a predictor for success. Surveillance imaging may be useful to detect future structural change, which will be the subject of future prospective studies.

Abstract Figure. AF ablation recurrence in young adults

P1381Improved outcome in ablation of ventricular tachycardia in patients with structural heart disease under general anaesthetic

Background

Catheter ablation is an important adjunct to device implantation for secondary prevention of ventricular tachycardia (VT). However, several factors may influence the success of ablations in terms of long-term freedom from VT recurrence. A thus far little examined factor is the use of general anaesthetic (GA) versus conscious sedation during the procedure, which has been shown to improve outcomes in persistent atrial fibrillation (AF) ablation.

Methods

Patients with structural heart disease VT undergoing ablations from January 2015 to March 2019 were retrospectively followed up at a single centre. End points were recurrent VT or device therapy (shock or anti-tachycardia pacing) at one year. Hazard ratios (HR) were generated using a multivariate Cox-regression proportional hazards model including variables of age at ablation, sex, amiodarone use at time of ablation, scar age, left ventricular ejection fraction, use of GA, and diagnosis of: diabetes mellitus (DM), hypertension (HTN), renal impairment or AF.

Results

79 patients (74 male, mean age 68.2+/- 10.3 years) were included. A substrate-based strategy of late potential ablation was employed. 69 had ischaemic and 10 had non-ischaemic cardiomyopathy. Mean scar age was 13.8 +/- 9.8 years; EF was 40-50% in 27 patients, 30-40% in 26 and < 30% in 26. 37 patients had implantable cardioverter defibrillators and 30 had cardiac resynchronisation therapy (CRT) defibrillator devices, 1 had a CRT- pacemaker device and 4 had dual chamber pacemakers. Comorbidities were: DM (16), HTN (31), renal impairment (13), AF (31). 62 patients (79.5%) were on amiodarone at the time of ablation. Mean procedure duration was 234.8 +/- 44.5 min and mean radiofrequency energy application time was 2247 +/- 862 s. 61 were first procedures and 18 were repeat procedures. One patient suffered a complication of groin haematoma. 62 patients (78.5%) underwent VT ablation under GA and 17 (21.5%) under sedation of midazolam and fentanyl. Patient characteristics did not differ between groups. Significant factors which increased freedom from VT recurrence or device therapy were HTN (88.9% vs 59.4%, HR 0.72, 95% confidence interval (CI): 0.007-0.75, p= 0.028), amiodarone treatment (50.0% vs 76.3%, HR 0.036, 95% CI: 0.003-0.404, p = 0.036) and ablation under GA rather than sedation (50.0% vs 75.0%, HR 0.055, 95% CI: 0.006-0.495, p = 0.01) (Fig 1).

Conclusions

In patients with structural heart disease undergoing VT ablation, outcomes are improved with the use of GA over conscious sedation.

Abstract Figure 1

P1419Persistent atrial fibrillation terminates during ablation more often using dispersion mapping than with fractionated electrogram mapping

Introduction

Persistent AF termination rates have increased since the advent of AF driver mapping, with a recent meta-analysis (Baykaner Circ AE 2018) of over 3200 patients showing improved 12 month freedom from AF/AT.  However,  recent randomised clinical trials have cast doubt on the efficacy of complex fractionated atrial electrograms (CFAE) based mapping strategies. We

set out to study a consecutive single centre series pre-and post- use of spatio-temporal dispersion (STD) to identify termination rates between the two approaches.

Methods

We recruited consecutive patients over 18 months at a single high volume tertiary centre undergoing first redo ablation for persistent AF. Patients were all

mapped using Pentarray to mark areas of substrate using the spatio-temporal dispersion (STD) method (Seitz JACC 2017).

Ablation was performed by a single operator using catheters to standardise equipment and workflow, to enable true

comparison of mapping and ablation results in a consecutive series.

Results

In total 38 patients were studied at redo ablation for persistent AF (age 69, 87% male, LA diameter 4.5cm). Termination of persistent

AF to SR (30%) or AT (70%) was obtained in 30/38 (79%) of the group with STD based substrate ablation vs. 1/38 (3%) in patients mapped

with CFAE targeting using identical equipment and operator (p < 0.001). Procedure time was no different between STD and CFAE based

approaches (263 vs. 248 mins, p = ns). Figure shows STD patterns (red arrows) on Pentarray in a 67 year old man anterior to left inferior

pulmonary vein (A), where ablation terminated AF to sinus rhythm. At 12 month follow up, 30/38 (79%) patients were in sinus rhythm with no AF detected on ECG or continuous monitoring.

Conclusions

In this single centre series of persistent AF ablations, the use of STD mapping increased rates of termination compared to a fractionation based mapping strategy alone, without increasing overall procedure time. Clinical outcome data suggest this translates into better 12 month clinical outcomes, and motivate prospective randomised trials to definitively study this technique.

Abstract Figure.

Role of Oropharyngeal Administration of Colostrum in Very Low Birth Weight Infants for Reducing Necrotizing Enterocolitis: A Randomized Controlled Trial

OBJECTIVE

This study aimed to study the role of oropharyngeal administration of colostrum (OAC) in very-low-birth-weight infants for reducing necrotizing enterocolitis (NEC).

STUDY DESIGN

In this randomized controlled trial, 117 infants were enrolled, 59 were randomized to OAC group and 58 to routine care group. Infants with birth weight ≤ 1,250 g and/or gestational age ≤ 30 weeks were enrolled. Infants in OAC group received maternal colostrum (0.2 mL), 0.1 mL on either side, after 24 hours of postnatal life and were given every 2 hour for the next 72 hours irrespective of the enteral feeding status of the neonate. The primary outcome of the study was the incidence of NEC (stage 2 or 3).

RESULTS

Baseline characteristics were comparable between the two groups. There was no significant reduction in the incidence of NEC in OAC group (0 [0%] vs. 3 [7.1%]; p = 0.11). There was significant reduction of 7 days of hospital stay in OAC group (34.2 ± 5.7 vs. 41.5 ± 6.7 days; p = 0.04).The incidence of early-onset sepsis, late-onset sepsis, blood culture positive sepsis, and ventilator-associated pneumonia were comparable between the two groups.

CONCLUSION

OAC is safe and reduces the duration of hospital stay.

P1451Catheter ablation in adults with Wolff-Parkinson-White syndrome: a "real-life" experience

Introduction. Radiofrequency catheter ablation (RFA) is 1st line treatment in symptomatic adult patients with Wolff-Parkinson-White syndrome (WPW). Patients with WPW are often quoted a high success rate for RFA but does this reflect reality? There is a paucity of recent literature and ongoing service developments in the UK may have a negative impact on success by reducing individual operator experience of adult WPW cases (i.e. increasing numbers of cardiac electrophysiologists in each department, patients more likely to undergo RFA as children). In contrast, technological developments (e.g. 3D mapping, steerable sheaths) may have a positive impact on success of RFA in WPW.

Methods. We collected data on all patients with WPW scheduled for 1st time ablation between Jan 2006 and Dec 2018. All patients undergoing re-do RFA during this time were excluded. For comparison, we divided this timeframe into three periods: 2006-9, 2010-13 and 2014-18.

Results. The number of patients scheduled for RFA and the outcome is listed in the Table. The overall success rate was 86.5% and this figure remained constant throughout the 13 year time-frame. Significant complications occurred in 1.17% of cases. 19.9% of patients scheduled for an ablation had no ablation attempted for various reasons (‘safe’ pathway, proximity to AV node etc).

Conclusion. In our centre, the number of adult cases of WPW scheduled for RFA year-on-year remains constant. The complication rate is in line with published literature. The RFA success rate is lower than the published data. As expected, success rate of RFA for WPW varies according to accessory pathway location. 1 in 5 cases scheduled for ablation did not proceed to ablation. This highlights an area where more effective resource planning from the outset can be undertaken.

Table 2006-9 2010-13 2014-18 Patients scheduled for RFA, n 181 152 179 Patients who underwent RFA, n 162 121 127 Overall RFA success rate, % (n) 85.6 (160) 86.6 (119) 87.4 (127) Success rate by AP location, % (n) Free wall Left 91.5 (71) 91.8 (49) 95.3 (64) Right 76.9 (13) 77.8 (9) 60.0 (5) Septal Anterior 77.8 (9) 88.9 (9) 100.0 (4) Mid 75.0 (8) 90.0 (10) 66.7 (3) Posterior 86.0 (57) 82.9 (41) 79.6 (49) RFA success rate in patients with Wolff-Parkinson-White syndrome. AP = accessory pathway, RFA = radiofrequency catheter ablation

The incidence and effect of resternotomy following cardiac surgery on morbidity and mortality: a 1-year national audit on behalf of the Association of Cardiothoracic Anaesthesia and Critical Care

Over 30,000 adult cardiac operations are carried out in the UK annually. A small number of these patients need to return to theatre in the first few days after the initial surgery, but the exact proportion is unknown. The majority of these resternotomies are for bleeding or cardiac tamponade. The Association of Cardiothoracic Anaesthesia and Critical Care carried out a 1-year national audit of resternotomy in 2018. Twenty-three of the 35 centres that were eligible participated. The overall resternotomy rate (95%CI) within the period of admission for the initial operation in these centres was 3.6% (3.37-3.85). The rate varied between centres from 0.69% to 7.6%. Of the 849 patients who required resternotomy, 127 subsequently died, giving a mortality rate (95%CI) of 15.0% (12.7-17.5). In patients who underwent resternotomy, the median (IQR [range]) length of stay on ICU was 5 (2-10 [0-335]) days, and time to tracheal extubation was 20 (12-48 [0-2880]) hours. A total of 89.3% of patients who underwent resternotomy were transfused red cells, with a median (IQR [range]) of 4 (2-7 [1-1144]) units of red blood cells. The rate (95%CI) of needing renal replacement therapy was 23.4% (20.6-26.5). This UK-wide audit has demonstrated that resternotomy after cardiac surgery is associated with prolonged intensive care stay, high rates of blood transfusion, renal replacement therapy and very high mortality. Further research into this area is required to try to improve patient care and outcomes in patients who require resternotomy in the first 24 h after cardiac surgery.

Advanced-PRF: Clinical evaluation in impacted mandibular third molar sockets

OBJECTIVE

This prospective study evaluated the efficacy and healing potential of modified formulation of PRF, commonly known as Advanced PRF (A-PRF) in impacted mandibular third molar extraction sockets.

MATERIALS AND METHODS

20 patients with bilateral impacted mandibular third molars were included in this study. Surgical disimpactions were done at 3-4 weeks interval in opposing quadrants of patient. One quadrant received A-PRF while the opposing quadrant in same patient was taken as control. Comparative evaluation was done in terms of pain assessment, analgesics required, swelling, soft tissue healing and trismus on 1st, 3 and 7day follow-up. Comparative assessment of bone healing was also done on 1st, 3and 6month follow-up.

RESULTS

This study involved 12 female and 8 male patients with in age range of 18-35 years. The evaluation of pain, swelling, trismus and soft tissue healing on 3rd postoperative day revealed considerable improvement on A-PRF sites as compared to control sites. The outcomes were found to be statistically significant with p values 0.008, 0.031, 0.0001, 0.05 respectively. Even the analgesic consumption was remarkably less when A-PRF was used (P=0.004). Bone healing evaluation in A-PRF sites on 1st, 3and 6month has shown significantly improved results with P<0.05.

CONCLUSION

Our study infers that A-PRF has enhanced the healing potential of soft tissue as well as bone in extraction socket. Apart from that it has also shown promising results in relief of immediate postoperative symptoms like pain, swelling and trismus which improves the comfort and acceptability of surgical procedures by patients. Enhanced healing and patient comfort in cost effective manner are the highlighting features of A-PRF.