Correlation Between Tissue Doppler Imaging Method (E/e') and Invasive Measurements of Left Ventricular Filling Pressures: A Systematic Review, Meta-Analysis, and Meta-Regression

OBJECTIVES

Evaluation of pulmonary capillary wedge pressure (PCWP) through right heart catheterization can indirectly provide an estimation of the filling pressure of the left ventricle. Echocardiography can estimate left ventricular compliance using mitral annular tissue Doppler imaging (TDI). The E/e' ratio refers to the correlation between the peak mitral inflow (E-wave) velocity and early diastolic tissue Doppler mitral annular velocity (e'). The main purpose of this systematic review was to establish the correlation between echocardiographic E/e' ratio and PCWP. The correlation between E/e' and left ventricular end-diastolic pressure (LVEDP) was evaluated as a secondary objective.

DESIGN

A systematic review and meta-analysis of observational studies was conducted. The search was based on Medline (PubMed), Scopus, and Web of Science.

SETTING

Intensive care unit or cardiac intensive care unit.

PARTICIPANTS

Adult patients.

INTERVENTIONS

Any study comparing the left ventricular filling pressure obtained by cardiac catheterization (reference) and echocardiographic evaluation, in particular TDI analysis (intervention), were included.

MEASUREMENTS AND MAIN RESULTS

The pooled analysis included 94 studies from the initially identified 7,304 records. The correlation was 0.48 (95% CI 0.42-0.54, Q = 420.52, I2 = 84.8%) for PCWP and 0.50 (95% CI 0.38-0.60, Q = 210.91, I2 = 89.1%) for LVEDP.

CONCLUSIONS

The E/e' ratio moderately correlated with PCWP/LVEDP. The correlation was stable irrespective of the sites where e' was measured, but each site has its own limitations for specific patient subpopulations. The correlation was weak in patients with heart failure with a preserved ejection fraction.

Correlation and concordance of carotid Doppler ultrasound and echocardiography with invasive cardiac output measurement in critically ill patients

BACKGROUND

Critical care management heavily relies on accurate cardiac output (CO) measurement. Echocardiography has been a mainstay in non-invasive cardiac monitoring; however, its comparability to invasive methods warrants further exploration. Recent studies have suggested the potential of carotid Doppler measurements as a promising approach to estimate CO. Despite this potential, the literature presents mixed outcomes regarding its reliability and accuracy. This study aims to evaluate the correlation and concordance between carotid Doppler ultrasonography and invasive hemodynamic monitoring in estimating CO in critically ill patients. Furthermore, it assesses the concordance and correlation between echocardiography CO and the standard invasive CO measurements.

METHODS

This concordance study involved critically ill adults requiring invasive CO measurement. Patients with arrhythmias, severe valvulopathy, pregnancy, and poor acoustic window were excluded. Statistical analyses comprised univariate analysis, Wilcoxon signed-rank test, Spearman correlation, and intraclass correlation coefficient. Ethical approval was granted by the institution's ethics committee.

RESULTS

A total of 49 critically ill patients were included, predominantly male (63.27%), with a median age of 57 years. Diagnoses included subarachnoid hemorrhage (53.06%) and heart failure (8.16%). Mean cardiac index was 3.36 ± 0.81 L/min/m2 and mean cardiac output was 5.98 ± 1.47 L/min. Spearman correlation coefficient between echocardiography and invasive CO measurements was 0.58 (p-value = p < 0.001), with an ICC of 0.59 for CO and 0.52 for cardiac index. Carotid measurements displayed no significant correlation with invasive CO.

CONCLUSION

There is a moderate correlation and concordance between echocardiography and invasive CO measurements. There is no significant correlation between carotid variables and invasive CO, underscoring the necessity for cautious interpretation and application, particularly in patients with distinctive cerebral blood flow dynamics.

Two Decades of CABG in the UK: A Propensity Matched Analysis of Outcomes by Conduit Choice

Background/Objectives: Grafting of LIMA to LAD has long been considered the gold-standard conduit choice for patients undergoing CABG. Despite this, the LSV remains the most used conduit by volume and some patients may not receive even a single arterial conduit. However, the outcomes in this group are not frequently explored. This study, therefore, compares in-hospital outcomes of patients who underwent CABG without any arterial conduits to those who received at least one arterial conduit. Methods: Retrospective propensity-matched database analysis of consecutive patients undergoing CABG in the UK between 1996 and 2019 using data from the National Adult Cardiac Surgery Audit. Results: 335,144 patients underwent CABG, with 6% receiving venous conduits only; matched outcomes are reported for 39,812 patients. In both unmatched and matched groups, we found a significant increase in mortality with the use of veins only (matched mortality 5.3% vs. 3.8%, p < 0.001) with estimated treatment effect for mortality OR 1.43, p < 0.001 (95% CI: 1.31-1.57). We also identified greater rates of post-operative dialysis, IABP insertion, and length of hospital stay in this group. Conclusions: We identified a significant increase in in-hospital mortality with the use of veins only compared to using at least one arterial graft to the LAD. While a single arterial graft should be prioritised wherever possible, venous revascularisation retains a critical role for specific patients. We must, therefore, continue to conduct research addressing the mechanisms underlying and propagating vein graft disease in order better to optimise outcomes for this niche patient group after CABG.

A 3-month-old male infant with Goldenhar syndrome: A clinical case report from Woldia, Northeast Ethiopia

Goldenhar syndrome is a multifactorial congenital anomaly that involves structures that develop from the first and second pharyngeal arches. In this report, we present a clinical case of a 3-month-old male infant diagnosed with Goldenhar syndrome, born to a known retro-viral infected mother who was receiving antiretroviral therapy. The baby was brought to the hospital with complaints related to upper respiratory system. On examination, he had typical signs and symptoms of Goldenhar syndrome: an asymmetrical face with small left facial bones, a low-set ear, left anophthalmia, an atretic left ear with only small ear appendages, and a complete cleft lip and palate. His family had no history of birth defects or exposure to the known causes of birth defects. The baby was treated for severe community-acquired pneumonia, the diagnosis for his current presentation to our hospital, and he is now on multidisciplinary follow-up for possible medical and surgical management of the Goldenhar syndrome.

Reliability and benefit of estimated continuous cardiac output measurement using shunt-side SpO2 monitor in hemodialysis

INTRODUCTION

Estimated continuous cardiac output (esCCO) is a novel technology that enables non-invasive and continuous monitoring of cardiac output. We compared the concordance in accuracies among esCCO measurements in the shunt limb and non-shunt limb.

METHODS

In this single-center prospective observational study, we include Japanese patients who underwent dialysis at our center between April 27, 2021, and February 28, 2023. Clinical accuracy of esCCO was evaluated in the shunted and non-shunted bilateral digits. Agreement between the measurements was analyzed using Lin's congruent correlation and Bland-Altman analysis.

RESULTS

For 43 individuals, Lin's concordance correlation coefficient was 0.9887 (95% confidence interval of 0.9886-0.9887) indicating good agreement. The values of esCCO measured in the shunt and non-shunt limbs were compatible. The percentage errors for the 43 patients with arterio-venous fistula (AVF) or arterio-venous graft (AVG), 32 with AVF, and 11 with AVG were 9.3%, 9.3%, and 8.9%, respectively.

CONCLUSION

esCCO could be used in shunt as well as non-shunt limbs during dialysis, allowing continuous and non-invasive hemodynamic monitoring.

Patterns, Outcomes and Economic Burden of Primary vs. Secondary Bloodstream Infections: A Single Center, Cross-Sectional Study

Bloodstream infections (BSIs) can be primary or secondary, with significant associated morbidity and mortality. Primary bloodstream infections (BSIs) are defined as infections where no clear infection source is identified, while secondary BSIs originate from a localized infection site. This study aims to compare patterns, outcomes, and medical costs between primary and secondary BSIs and identify associated factors. Conducted at the University Hospital of Patras, Greece, from May 2016 to May 2018, this single-center retrospective cohort study included 201 patients with confirmed BSIs based on positive blood cultures. Data on patient characteristics, clinical outcomes, hospitalization costs, and laboratory parameters were analyzed using appropriate statistical methods. Primary BSIs occurred in 22.89% (46 patients), while secondary BSIs occurred in 77.11% (155 patients). Primary BSI patients were younger and predominantly nosocomial, whereas secondary BSI was mostly community-acquired. Clinical severity scores (SOFA, APACHE II, SAPS, and qPitt) were significantly higher in primary compared to secondary BSI. The median hospital stay was longer for primary BSI (21 vs. 12 days, p < 0.001). Although not statistically significant, mortality rates were higher in primary BSI (43.24% vs. 26.09%). Total care costs were significantly higher for primary BSI (EUR 4388.3 vs. EUR 2530.25, p = 0.016), driven by longer hospital stays and increased antibiotic costs. This study underscores the distinct clinical and economic challenges of primary versus secondary BSI and emphasizes the need for prompt diagnosis and tailored antimicrobial therapy. Further research should focus on developing specific management guidelines for primary BSI and exploring interventions to reduce BSI burden across healthcare settings.

Left ventricle pedunculated thrombi risks and outcomes: a case report and literature review

A 42-year-old male with ischemic cardiomyopathy presented with acute bilateral femoral artery embolization. After management with embolectomy and fasciotomy in both femoral arteries, transthoracic echocardiography revealed two pedunculated highly mobile left ventricle (LV) thrombi. Given the procedural risk, anticoagulation therapy was recommended over surgery. However, the bleeding risk impeded the continuation of anticoagulation, which increased the thrombus size. Multiorgan failure and disseminated intravascular coagulopathy followed and the patient died. We also systematically reviewed the PubMed and Scopus databases for pedunculated LV thrombi cases and retrieved 74 and 63 reports respectively. Of these, 37 relevant reports (45 cases) plus 11 reports from the manual search were included for data extraction, a total of 56 cases besides our case. Based on the etiologies and risks, LV thrombi are predictable and preventable, especially after ischemic events. A clear diagnostic algorithm and vigilant follow-up are needed as well as multidisciplinary management once a diagnosis is confirmed.

An Automated Text Messaging Intervention to Reduce Substance Use Self-Stigma (Project RESTART): Protocol for a Feasibility and Acceptability Pilot Study

BACKGROUND

Stigma is a barrier to treatment and harm reduction seeking in people who use drugs. Most stigma reduction interventions offer psychotherapy or psychoeducation in group-based clinical settings, failing to reach people who are not in treatment. SMS text messaging is an effective and acceptable modality for delivering health information to people who use drugs and may be a suitable conduit for providing information and advice to understand and cope with stigma.

OBJECTIVE

This paper presents the protocol for a study that aims to determine the feasibility, acceptability, and preliminary effectiveness of a 4-week automated SMS text message intervention to increase stigma resistance and reduce self-stigma in people who use drugs.

METHODS

We designed a novel automated SMS text message intervention to address the four personal-level constructs of stigma resistance: (1) not believing stigma and catching and challenging stigmatizing thoughts, (2) empowering oneself through learning about substance use and one's recovery, (3) maintaining one's recovery and proving stigma wrong, and (4) developing a meaningful identity and purpose apart from one's substance use. Theory-based messages were developed and pilot-tested in qualitative elicitation interviews with 22 people who use drugs, resulting in a library of 56 messages. In a single-group, within-subjects, community-based pilot trial, we will enroll 30 participants in the Resisting Stigma and Revaluating Your Thoughts (RESTART) intervention. Participants will receive 2 daily SMS text messages for 4 weeks. Implementation feasibility will be assessed through recruitment, enrollment, retention, and message delivery statistics. User feasibility and acceptability will be assessed at follow-up using 23 survey items informed by the Theoretical Framework of Acceptability. Primary effectiveness outcomes are changes in self-stigma (Substance Abuse Self-Stigma Scale) and stigma resistance (Stigma Resistance Scale) from baseline to follow-up measured via a self-administered survey. Secondary outcomes are changes in hope (Adult Dispositional Hope Scale) and self-esteem (Rosenberg Self-Esteem Scale). Feasibility and acceptability will be assessed with descriptive statistics; effectiveness outcomes will be assessed with paired 2-tailed t tests, and group differences will be explored using ANOVA. Overall, 12 participants will also be selected to complete acceptability interviews.

RESULTS

This pilot study was funded by the National Institute on Drug Abuse in April 2023 and received regulatory approval in January 2024 by the University of North Carolina-Chapel Hill Institutional Review Board. Recruitment and enrollment began in March 2024. Follow-up visits are expected to conclude by May 2024. Results will be disseminated in relevant peer-reviewed journals.

CONCLUSIONS

To the best of our knowledge, this is the first study to address substance use stigma via a self-help SMS text messaging program. Results will add to the nascent literature on stigma reduction in people who use drugs. This protocol may interest researchers who are considering text messaging to address psychosocial needs in hard-to-reach populations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06281548; https://clinicaltrials.gov/ct2/show/NCT06281548.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59224.

Lymphedema self-management mobile application with nurse support for post breast cancer surgery survivors: description of the design process and prototype evaluation

BACKGROUND

Self-management is the key to control breast cancer related lymphedema (BCRL). This study aimed to develop a mobile application with nurse support for lymphedema self-management and evaluate its usability from the patients' points of view.

METHODS

This applied developmental study was conducted on 87 women in a lymphedema clinic, Shiraz, Iran, May-November 2023. The study included three phases: development, distribution of the application and usability evaluation. In the development phase, the researchers developed application using the Java programming language. In distribution phase, the application was installed on the participants' phones. For usability evaluation, 87 patients completed the user satisfaction questionnaire after three months access to the application. Data was analyzed using descriptive and analytical statistics using SPSS software 22. P-value less than 0.05 was considered significant.

RESULTS

We designed a self-management application specific to BCRL that included ten unique modules mainly related to patient education, interaction with peers and nurse, self-management support, and settings. The application mean usability score was 7.72 ± 1.08. The usability dimensions of "screen" (8.06 ± 1.02) and "terminology and systems information" (7.29 ± 1.62) received the highest and lowest mean scores, respectively.

CONCLUSION

The application has new features to meet more patients' needs compared to what other existing lymphedema self-management applications already have addressed. The findings showed that the participants rated the application usability at the "good" level that is similar to some previous studies. Considering the unique nature of the application and its favorable usability, we recommend its use for BCRL self-management.

Serum concentrations of levosimendan and its metabolites OR-1855 and OR-1896 in cardiac surgery patients with cardiopulmonary bypass

Background

The inotropic drug levosimendan is often used as an individualized therapeutic approach perioperatively in cardiac surgery patients with cardiopulmonary bypass (CPB). Data regarding serum concentrations of levosimendan and its metabolites within this context is lacking.

Methods

In this retrospective descriptive proof-of-concept study, total serum concentrations (TSC) and unbound fractions (UF) of levosimendan and its metabolites OR-1896 and OR-1855 in cardiac surgery patients with CPB were measured using LC-ESI-MS/MS. Simulation of expected levosimendan TSC was performed using Pharkin 4.0. Serum NT-proBNP was assessed with ELISA.

Results

After levosimendan infusion (1.25 mg or 2.5 mg, respectively) after anaesthesia induction, a median TSC of 1.9 ng/ml and 10.4 ng/ml was determined in samples taken directly after surgery (T1). Median TSC of 7.6 ng/ml and 22.0 ng/ml, respectively, were simulated at T1. Whereas 1.1 ng/ml and 1.6 ng/ml TSC of OR-1896, respectively, was quantified the day after surgery (T2), TSC of the intermediate metabolite OR-1855 was mostly below the lower limit of quantification (LLOQ). The UF was 0.5% and 1.1% for levosimendan and 64.1% and 52.1% for OR-1896, respectively, with over half the samples being below LLOQ. NT-proBNP concentrations before surgery and T2 did not differ.

Discussion

The low TSC, UF and unchanged NT-proBNP levels in combination with high variation of serum levels between patients suggest a need for optimized dosing regimen of levosimendan combined with therapeutic drug monitoring for such an individualized approach. In addition, the differences between the measured and estimated concentrations may suggest a possible influence of CPB on levosimendan serum concentrations.

Brown adipose tissue-derived FGF21 mediates the cardioprotection of dexmedetomidine in myocardial ischemia/reperfusion injury

Brown adipose tissue (BAT) plays a critical role in regulating cardiovascular homeostasis through the secretion of adipokines, such as fibroblast growth factor 21 (FGF21). Dexmedetomidine (DEX) is a selective α2-adrenergic receptor agonist with a protection against myocardial ischemia/reperfusion injury (MI/RI). It remains largely unknown whether or not BAT-derived FGF21 is involved in DEX-induced cardioprotection in the context of MI/RI. Herein, we demonstrated that DEX alleviated MI/RI and improved heart function through promoting the release of FGF21 from interscapular BAT (iBAT). Surgical iBAT depletion or supplementation with a FGF21 neutralizing antibody attenuated the beneficial effects of DEX. AMPK/PGC1α signaling-induced fibroblast growth factor 21 (FGF21) release in brown adipocytes is required for DEX-mediated cardioprotection since blockade of the AMPK/PGC1α axis weakened the salutary effects of DEX. Co-culture experiments showed that DEX-induced FGF21 from brown adipocytes increased the resistance of cardiomyocytes to hypoxia/reoxygenation (H/R) injury via modulating the Keap1/Nrf2 pathway. Our results provided robust evidence that the BAT-cardiomyocyte interaction is required for DEX cardioprotection, and revealed an endocrine role of BAT in DEX-mediating protection of hearts against MIRI.

The Feasibility of the Diabetes Self-Management Coaching Program in Primary Care: A Mixed-Methods Randomized Controlled Feasibility Trial

BACKGROUND

Diabetes mellitus, a chronic metabolic disorder associated with elevated blood sugar levels, is a significant cause of morbidity, mortality, and disability globally. The rampant rise in the prevalence of diabetes presents a public health burden and a challenge to the primary care setting. Diabetes self-management coaching is an emergent, client-centered, solution-focused approach to enhance self-efficacy and self-care behavior, control glycemia, and prevent acute and chronic complications. Currently, there is no diabetes self-management support strategy in the primary care setting in Ethiopia. Therefore, this study assessed the feasibility, acceptability, and fidelity of implementing the Diabetes Self-Management Coaching Program in primary care in Ethiopia.

METHOD

A single-center, single-blinded, parallel group mixed-methods feasibility randomized control design was applied to assess the feasibility, acceptability, and fidelity of the Diabetes Self-Management Coaching Program in primary care. Adult patients with type 2 diabetes with HbA1c ≥ 7%, taking diabetic medication, and living in Gondar town were included in the study. A block randomization technique with a block size of four was used to allocate participants into the treatment and control groups. The treatment group attended a 12-week Diabetes Self-Management Coaching Program in addition to undergoing usual care, while the control group received the usual care for the same period. Data were collected at baseline, at the end of the intervention, and after the follow-up period. Descriptive statistics such as the frequency, mean, median, and standard deviations were computed. Based on the normality assessment, the baseline group difference was examined using the independent sample Student's t-test, the Mann-Whitney U test, and the chi-square test.

RESULT

This study's eligibility, recruitment, retention, and adherence rates were 23%, 70%, 90%, and 85%, respectively. Both the qualitative and quantitative findings show that the program was feasible to implement in primary care and acceptable to the participants. The fidelity assessment of the Diabetes Self-Management Coaching Program indicates an appropriate intervention implementation.

CONCLUSIONS

This study demonstrated remarkable recruitment, retention, and adherence rates. The Diabetes Self-Management Coaching Program was feasible, acceptable, and implementable in primary care in Ethiopia. As a result, we recommend that a large-scale multi-center cluster randomized controlled trial with an adequate sample can be designed to evaluate the effect of the DSM Coaching Program on clinical and behavioral outcomes.

Biodegradation of phenol-contaminated soil and plant growth promotion by Myroides xuanwuensis H13

Physicochemical methods for remediating phenol-contaminated soils are costly and inefficient, making biodegradation an environmentally friendly alternative approach. This study aims to screen for potential phenol-degrading bacteria and to verify the removal capacities of a selected strain in a bioaugmentation experiment at the greenhouse level using Brassica chinensis L. (Chinese cabbage) as the model plant and phenol-contaminated soil. In parallel, pot experiments were conducted using a collaborative approach based on this model system. We found that Myroides xuanwuensis strain H13 showed a high degradation capability, with a 97.67% efficiency in degrading 100 mg/L phenol. Under shaking flask conditions, H13 facilitated the solubilization of tricalcium phosphate and potassium feldspar powder. Pot experiments suggested a phenol removal percentage of 89.22% and enhanced availability of soil phosphorus and potassium for plants with H13 inoculation. In this case, the abundance of soil microbes and the activity of soil enzymes significantly increased as well. Furthermore, both photosynthesis and the antioxidant system in Chinese cabbage were enhanced following H13 inoculation, resulting in its increased yield and quality. Partial least squares path modeling revealed that H13 can primarily affect plant root growth, with a secondary impact on photosynthesis. These findings highlight the potential of biodegradation from phenol-degrading bacteria as a promising strategy for efficient phenol removal from soil while promoting plant growth and health.IMPORTANCEThis study is significant for environmental remediation and agriculture by its exploration of a more environmentally friendly and cost-effective bio-strategy in treating phenol-contaminated soil. These findings have essential implications for environmental remediation efforts and sustainable agriculture. By utilizing the biodegradation capabilities of Myroides xuanwuensis strain H13, it is possible to remove phenol contaminants from the soil efficiently, reducing their negative effects. Furthermore, the enhanced growth and health of the Chinese cabbage plants indicate the potential of this approach to promote sustainable crop production.

Bone Imaging of the Knee Using Short-Interval Delta Ultrashort Echo Time and Field Echo Imaging

Background: Computed tomography (CT) is the preferred imaging modality for bone evaluation of the knee, while MRI of the bone is actively being developed. We present three techniques using short-interval delta ultrashort echo time (δUTE), field echo (FE), and FE with high resolution-deep learning reconstruction (HR-DLR) for direct bone MRI. Methods: Knees of healthy volunteers (n = 5, 3 females, 38 ± 17.2 years old) were imaged. CT-like images were generated by averaging images from multiple echoes and inverting. The bone signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were determined. Results: The δUTE depicted a cortical bone with high signal intensity but could not resolve trabeculae. In contrast, both the FE and FE HR-DLR images depicted cortical and trabecular bone with high signal. Quantitatively, while δUTE had a good bone SNR of ~100 and CNR of ~40 for the cortical bone, the SNR for the FE HR-DLR was significantly higher (p < 0.05), at over 400, and CNR at over 200. Conclusions: For 3D rendering of the bone surfaces, the δUTE provided better image contrast and separation of bone from ligaments and tendons than the FE sequences. While there still is no MRI technique that provides a perfect CT-like contrast, continued advancement of MRI techniques may provide benefits for specific use cases.

The effect of longer epidural duration after open pancreaticoduodenectomy on pain and mobilisation: A retrospective single-centre analysis

BACKGROUND

The optimal length of epidural use following open pancreaticoduodenectomy has not been defined. The aim of this study was to investigate whether the length of patient-controlled epidural analgesia affected pain and ability to mobilise on epidural termination following open pancreaticoduodenectomy in the context of enhanced recovery after surgery.

METHODS

A retrospective single-centre cohort analysis was performed between November 2015 and December 2021 on patients who underwent open pancreaticoduodenectomy. As part of a continual review process of the enhanced recovery after surgery protocol, patient-controlled epidural analgesia duration changed allowing stratification of patients into either three- or five-day patient-controlled epidural analgesia groups.

RESULTS

Of the 196 patients identified, 157 were included with 80 (50.9%) and 77 (49.1%) allocated to the three-day and five-day patient-controlled epidural analgesia groups, respectively. Patient-controlled epidural analgesia termination on postoperative day 3 was associated with transiently higher pain and less mobilisation, although no greater rescue analgesia requirement. Conversely, longer patient-controlled epidural analgesia usage following open pancreaticoduodenectomy was associated with less pain and greater mobilisation in the immediate postoperative period.

CONCLUSIONS

Earlier patient-controlled epidural analgesia termination transiently leads to increased pain and decreased mobilisation following open pancreaticoduodenectomy. Ensuring appropriate analgesia requirements or longer patient-controlled epidural analgesia usage should be considered to avoid patient discomfort and enhance recovery.

Is Cardiac Surgery Safe During Pregnancy? A 40-Year Single-Institution Experience

BACKGROUND

Limited data exist to characterize maternal and fetal outcomes during pregnancy undergoing cardiac operations using cardiopulmonary bypass.

METHODS

A retrospective review was performed of all pregnant individuals who underwent cardiac surgery using cardiopulmonary bypass at a single center from 1978 to 2023. Descriptive statistical analysis was performed, with a median reported for continuous variables and incidence for dichotomous variables.

RESULTS

Twenty-nine pregnant patients with a median age of 28 years (interquartile range [IQR], 25-32 years) years underwent cardiac surgery using cardiopulmonary bypass at a median gestation of 25 weeks (IQR, 16-29 weeks). Surgery was performed in the first trimester for 3 patients (10%), second trimester for 16 (55%), and third trimester for 10 (35%). Procedures were emergent in 15 (52%) and urgent in 14 (48%). There was 1 (3%) maternal death 2 days after mechanical aortic valve thrombectomy and 5 (17%) fetal losses. Fourteen patients who underwent cardiac surgery using cardiopulmonary bypass with continuing pregnancy experienced a 29% fetal mortality rate, and 7 patients underwent delivery before surgery and experienced 14% fetal mortality. Among cases of fetal loss, surgery was performed at a median of 25 weeks (IQR, 21-26 weeks) compared with a median of 23 weeks (IQR, 20-29 weeks) in cases without fetal loss (P = .55).

CONCLUSIONS

Cardiac surgery during pregnancy was associated with low maternal mortality but significant fetal mortality. This single-institution series supports consideration of cesarean delivery before cardiopulmonary bypass procedures if the fetus is of a viable gestational age to minimize mortality.

Preservation of Vocal Function in Amyotrophic Lateral Sclerosis (ALS) Patients Following Percutaneous Dilatational Tracheostomy (PDT) and Adjuvant Therapies

The study aimed to evaluate the efficacy of percutaneous dilatational tracheostomy (PDT) combined with adjuvant therapies in preserving vocal function in amyotrophic lateral sclerosis (ALS) patients.

METHODS

We performed a retrospective analysis of 47 ALS patients who underwent PDT at the Rodem Hospital from 2021 to 2023. Post-operatively, these patients were provided with a comprehensive treatment plan that included regenerative injection therapy, low-frequency electrical stimulation, respiratory rehabilitation, and swallowing rehabilitation therapy. Additionally, a balloon reduction program was implemented for effective tracheostomy tube (T-tube) management. The preservation of vocal functions was evaluated 4 weeks following the procedure.

RESULTS

While some patients maintained or slightly improved their ALSFRS-R speech scores, the overall trend indicated a decrease in speech scores post-PDT. This suggests that PDT in combination with adjuvant therapies may not universally improve vocal function, but can help maintain it in certain cases.

CONCLUSIONS

Our findings indicate that PDT combined with mesotherapy, low-frequency electrical stimulation, and swallowing rehabilitation therapy may play a role in maintaining vocal function in limb type ALS patients, though further research is needed to optimize patient management and to validate these results.

Laryngeal Vibrotactile Stimulation Is Feasible, Acceptable To People With Unexplained Chronic Cough

OBJECTIVES

Unexplained chronic cough (UCC) is common and has significant impacts on quality of life. Ongoing cough can sensitize the larynx, increasing the urge to cough and perpetuating the cycle of chronic cough. Vibrotactile stimulation (VTS) of the larynx is a noninvasive stimulation technique that can modulate laryngeal somatosensory and motor activity. Study objectives were to assess feasibility and acceptability of VTS use by people with UCC. Secondarily, changes in cough-related quality of life measures were assessed.

METHODS

Adults with UCC recorded cough measures at baseline and after completing 2 weeks of daily VTS. Feasibility and acceptability were assessed through participant-reported device use and structured feedback. Cough-related quality of life measures were the Leicester Cough Questionnaire (LCQ) and the Newcastle Laryngeal Hypersensitivity Questionnaire (NLHQ).

RESULTS

Nineteen adults participated, with mean age 67 years and cough duration 130 months. Notably, 93% of planned VTS sessions were logged, 94% of participants found the device comfortable to wear, 89% found it easy to operate and 79% would recommend it to others. Pre-post LCQ change achieved a minimal important difference (MID) (mean 1.3 [SD 2.4, p = 0.015]). NLHQ scores improved, but did not reach an MID.

CONCLUSIONS

Laryngeal VTS use was feasible and acceptable for use by patients with UCC and was associated with a meaningful improvement in cough-related quality of life. Future studies will include VTS dose refinement and the inclusion of a comparison arm to further assess the potential for laryngeal VTS as a novel treatment modality for UCC.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Cardiac magnetic resonance imaging for discrimination of hypertensive heart disease and hypertrophic cardiomyopathy: a systematic review and meta-analysis

Introduction

Differentiating hypertensive heart disease (HHD) from hypertrophic cardiomyopathy (HCM) is crucial yet challenging due to overlapping clinical and morphological features. Recent studies have explored the use of various cardiac magnetic resonance (CMR) parameters to distinguish between these conditions, but findings have remained inconclusive. This study aims to identify which CMR parameters effectively discriminate between HHD and HCM and to investigate their underlying pathophysiological mechanisms through a meta-analysis.

Methods

The researchers conducted a systematic and comprehensive search for all studies that used CMR to discriminate between HHD and HCM and calculated the Hedges'g effect size for each of the included studies, which were then pooled using a random-effects model and tested for the effects of potential influencing variables through subgroup and regression analyses.

Results

In this review, 26 studies encompassing 1,349 HHD and 1,581 HCM cases were included for meta-analysis. Analysis revealed that HHD showed a significant lower in T1 mapping (g = -0.469, P < 0.001), extracellular volume (g = -0.417, P = 0.024), left ventricular mass index (g = -0.437, P < 0.001), and maximal left ventricular wall thickness (g = -2.076, P < 0.001), alongside a significant higher in end-systolic volume index (g = 0.993, P < 0.001) and end-diastolic volume index (g = 0.553, P < 0.001), compared to HCM.

Conclusion

This study clearly demonstrates that CMR parameters can effectively differentiate between HHD and HCM. HHD is characterized by significantly lower diffuse interstitial fibrosis and myocardial hypertrophy, along with better-preserved diastolic function but lower systolic function, compared to HCM. The findings highlight the need for standardized CMR protocols, considering the significant influence of MRI machine vendors, post-processing software, and study regions on diagnostic parameters. These insights are crucial for improving diagnostic accuracy and optimizing treatment strategies for patients with HHD and HCM.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023470557, PROSPERO (CRD42023470557).

Medications that Regulate Gastrointestinal Transit Influence Inpatient Blood Glucose

Objective

A multitude of factors affect a hospitalized individual's blood glucose (BG), making BG difficult to predict and manage. Beyond medications well established to alter BG, such as beta-blockers, there are likely many medications with undiscovered effects on BG variability. Identification of these medications and the strength and timing of these relationships has potential to improve glycemic management and patient safety.

Materials and Methods

EHR data from 103,871 inpatient encounters over 8 years within a large, urban health system was used to extract over 500 medications, laboratory measurements, and clinical predictors of BG. Feature selection was performed using an optimized Lasso model with repeated 5-fold cross-validation on the 80% training set, followed by a linear mixed regression model to evaluate statistical significance. Significant medication predictors were then evaluated for novelty against a comprehensive adverse drug event database.

Results

We found 29 statistically significant features associated with BG; 24 were medications including 10 medications not previously documented to alter BG. The remaining five factors were Black/African American race, history of type 2 diabetes mellitus, prior BG (mean and last) and creatinine.

Discussion

The unexpected medications, including several agents involved in gastrointestinal motility, found to affect BG were supported by available studies. This study may bring to light medications to use with caution in individuals with hyper- or hypoglycemia. Further investigation of these potential candidates is needed to enhance clinical utility of these findings.

Conclusion

This study uniquely identifies medications involved in gastrointestinal transit to be predictors of BG that may not well established and recognized in clinical practice.

Efficacy of bilateral catheter superficial parasternal intercostal plane blocks using programmed intermittent bolus for opioid-sparing postoperative analgesia in cardiac surgery with sternotomy: A randomized, double-blind, placebo-controlled trial

STUDY OBJECTIVE

This study investigated whether catheter superficial parasternal intercostal plane (SPIP) blocks, using a programmed intermittent bolus (PIB) with ropivacaine, could reduce opioid consumption while delivering enhanced analgesia for a period exceeding 48 h following cardiac surgery involving sternotomy.

DESIGN

A double-blind, prospective, randomized, placebo-controlled trial.

SETTING

University-affiliated tertiary care hospital.

PATIENTS

60 patients aged 18 or older, scheduled for cardiac surgery via sternotomy.

INTERVENTIONS

The patients were randomly assigned in a 1:1 ratio to either the ropivacaine or saline group. After surgery, patients received bilateral SPIP blocks for 48 h with 0.4% ropivacaine (20 mL per side) for induction, followed by bilateral SPIP catheters using PIB with 0.2% ropivacaine (8 mL/side, interspersed with a 2-h interval) or 0.9% normal saline following the same administration schedule. All patients were administered patient-controlled analgesia with hydromorphone.

MEASUREMENTS

The primary outcome was the cumulative morphine equivalent consumption during the initial 48 h after the surgery. Secondary outcomes included postoperative pain assessment using the Numeric Rating Scale (NRS) at rest and during coughing at designated intervals for three days post-extubation. Furthermore, recovery indicators and ropivacaine plasma levels were diligently documented.

MAIN RESULTS

Cumulative morphine consumption within 48 h in ropivacaine group decreased significantly compared to saline group (25.34 ± 31.1 mg vs 76.28 ± 77.2 mg, respectively; 95% CI, -81.9 to -20.0, P = 0.002). The ropivacaine group also reported lower NRS scores at all recorded time points (P < 0.05) and a lower incidence of nausea and vomiting than the saline group (3/29 vs 12/29, respectively; P = 0.007). Additionally, the ropivacaine group showed significant improvements in ambulation (P = 0.018), respiratory exercises (P = 0.006), and self-reported analgesia satisfaction compared to the saline group (P = 0.016).

CONCLUSIONS

Bilateral catheter SPIP blocks using PIB with ropivacaine reduced opioid consumption over 48 h, concurrently delivering superior postoperative analgesia in adult cardiac surgery with sternotomy.

Rationale and design of a single-center randomized trial to compare the graft patency between the radial artery and the no-touch saphenous vein in coronary artery bypass grafting surgery (GRAFT-CAB Study)

BACKGROUND

Previous studies suggested only the radial artery and the No-touch (NT) technique were effective in reducing graft occlusion after coronary artery bypass grafting (CABG) surgery. However, there is no randomized trial comparing these 2 graft conduits. The optimum second conduit for CABG remains undetermined.

MATERIALS AND METHODS

This study is a prospective, single-center randomized clinical trial, aiming to compare the graft patency between the radial artery and the NT vein graft. All patients undergoing isolated CABG with left internal mammary artery (LIMA) plus at least 2 additional grafts will be considered eligible. About 774 cases (516 in the radial artery group and 258 in the NT vein group) will be enrolled in over 1 to 2 years. Participants will be randomized and allocated to two bypass strategies: the LIMA plus 1 radial artery and 1 conventional vein graft, or the LIMA plus 2 NT vein grafts. The primary outcome is graft occlusion at 1 year after CABG evaluated by CT angiography. The secondary outcomes include graft occlusion at 3 and 5 years and major adverse cardiac or cerebrovascular events at 1, 3, and 5 years follow-ups.

DISCUSSION

This study will define whether or not the NT vein has a lower graft occlusion rate than the radial artery in short and mid-term follow-ups, and provide new evidence for the second conduit choice in CABG surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06014047. Registered on October 15th, 2023.

Comparison of Community Pharmacist and Non-Community Pharmacist Perceptions of a Community Pharmacy Specialty Board Certification

Background: Pharmacy board certification provides pharmacists with formal recognition of their careers and their involvement in direct and comprehensive patient care. Credentialing as a board-certified pharmacist demonstrates that the pharmacist has specialized expertise and is able to provide advanced level patient care in a specific pharmacy practice specialty. There is currently not a community pharmacy board certification available in the United States. With the expanding role and clinical expectations of community pharmacists nationwide, perspectives regarding the utility of a community pharmacy specialty board certification are necessary. Methods: A cross-sectional survey with demographic and perception questions (5-point Likert scale) was distributed electronically via Qualtrics. A random sample of pharmacists registered in Rhode Island, Ohio, and Nebraska were selected and surveyed. Results: 53 survey responses were collected. There was a statistically significant difference in board certification history (P = .001) and history of post-graduate training (P < .001) between community pharmacists and non-community pharmacists. Community pharmacists were more likely to simultaneously see community pharmacists as general practitioners (P = .030) and as pharmacy practice specialists (P = .001). Non-community pharmacists were more likely to be familiar with current maintenance requirements for pharmacy board certifications (P < .001) and to feel that a board certification is an appropriate indicator of experience in a pharmacy specialty area (P = .016). Conclusion: Views regarding community pharmacy and board certification differed between community and non-community pharmacists. There was not a statistically significant difference in the perceived value of community pharmacy board certification between community and non-community pharmacist.

Dexmedetomidine mitigates acute kidney injury after coronary artery bypass grafting: a prospective clinical trial

INTRODUCTION AND OBJECTIVES

To evaluate the impact of dexmedetomidine impact on cardiac surgery-associated acute kidney injury (CSA-AKI), kidney function, and metabolic and oxidative stress in patients undergoing coronary artery bypass grafting with heart-lung machine support.

METHODS

A randomized double-masked trial with 238 participants (50-75 years) undergoing coronary artery bypass grafting was conducted from January 2021 to December 2022. The participants were divided into Dex (n=119) and NS (n = 119) groups. Dex was administered at 0.5 mcg/kg over 10minutes, then 0.4 mcg/kg/h until the end of surgery; the NS group received equivalent saline. Blood and urine were sampled at various time points pre- and postsurgery. The primary outcome measure was the incidence of CSA-AKI, defined as the occurrence of AKI within 96hours after surgery.

RESULTS

The incidence of CSA-AKI was significantly lower in the Dex group than in the NS group (18.26% vs 32.46%; P=.014). Substantial increases were found in estimated glomerular filtration rate value at T4-T6 (P<.05) and urine volume 24hours after surgery (P<.01). Marked decreases were found in serum creatinine level, blood glucose level at T1-T2 (P<.01), blood urea nitrogen level at T3-T6 (P<.01), free fatty acid level at T2-T3 (P<.01), and lactate level at T3-T4 (P<.01).

CONCLUSIONS

Dex reduces CSA-AKI, potentially by regulating metabolic disorders and reducing oxidative stress. Registered with the Chinese Clinical Study Registry (No. ChiCTR2100051804).

Management of Fallot's Uncorrected Tetralogy in Adulthood: A Narrative Review

The majority of cyanotic congenital cardiac defects are caused by the tetralogy of Fallot. Some symptoms include a biventricular connection of the aortic root, right ventricular hypertrophy, blockage of the right ventricular outflow tract, and a ventricular septal defect. Our understanding of tetralogy of Fallot (TOF) has significantly advanced since it was first described in 1888, and early diagnosis has led to improved surgical management and increased life expectancy. Adults with unrepaired and repaired TOF present with a range of late complications, including heart failure, the need for re-interventions, and late arrhythmias. Right ventricular (RV) failure, often caused by chronic pulmonary regurgitation, is a significant cause of heart failure in patients with TOF. Current treatment options are limited, and mainstay surgical procedures such as pulmonary-valve replacement (PVR), trans-annular repair (TAR), or infundibular widening repair have not shown a significant reduction in preventing right ventricular (RV) failure or death. Here, we explain the mechanisms of RV failure in ToF, chronic pulmonary regurgitation, heart failure, and secondary polycythemia. HF management in untreated adults is discussed. The progression of the disease, as well as complications, are also discussed. The treatment plan and the need to investigate the best management approach for this unsolved problem are included. This review aims to fill the knowledge gaps and supply valuable information regarding mechanisms of RV failure, chronic pulmonary regurgitation, and secondary polycythemia. To summarize, a new combat strategy must be found to battle RVF, and a more profound vision of these mechanisms is required. If it is not corrected, it will be one of the future research lines that will contribute to designing more efficacious treatment techniques for adults with TOF.

Early administration of ketorolac after cardiac surgery and postoperative complications: Analysis of the MIMIC-IV database

Inflammation may contribute to postoperative cardiac complications and ketorolac, an anti-inflammatory agent inhibiting cyclooxygenase (COX), shows promise in enhancing cardiac graft patency by suppressing endothelial cell proliferation in animal studies. However, the safety of postoperative ketorolac use remains controversial. This study investigates the association between early ketorolac application and complications following cardiac surgery. Data from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database fueled this retrospective cohort study. The primary outcome is a composite of mortality, pulmonary insufficiency, severe acute kidney injury (AKI), hemorrhage or hematoma, infection, cardiogenic shock, and cerebrovascular infarction postcardiac surgery. Propensity score matching (PSM; 1:1 match, caliper 0.2), multivariate logistic regression, interaction stratification analysis, pairwise algorithmic, and overlap weight model analyses were employed. Following inclusion and exclusion criteria, 7143 patients who underwent valvular surgery or coronary artery bypass grafting (CABG) were included. PSM created a balanced cohort of 3270 individuals (1635 in the ketorolac group). The matched cohort exhibited an 8.1% overall rate of postoperative complications, with a lower composite outcome rate in patients receiving ketorolac within 48 h of surgery compared with those without (PSM, OR 0.70 [95% CI, 0.54-0.90]). Consistent associations were observed in total cohort analyses, sensitivity, and subgroup analyses. Early ketorolac use within 48 h post-CABG or valvular procedures in adults is independently associated with a lower incidence of composite postoperative adverse events. Prospective trials are warranted to assess causality.

Perioperative Implications in a Hypertrophic Cardiomyopathy Patient Undergoing Endonasal Orbital Decompression: A Case Report

Thyroid eye disease (TED) is an autoimmune disease of the retro-ocular tissue and occurs in patients with Graves' disease with hyperthyroidism. In severe cases, it can lead to vision loss; hence, timely management is important. Hypertrophic cardiomyopathy (HCM) is one of the systemic manifestations related to hyperthyroidism. We present a case of successful perioperative management of Graves' disease with TED and HCM posted for endonasal decompression surgery. Hyperthyroidism itself has many implications on perioperative anesthetic management, which can become more complicated when associated with co-existing HCM. However, our case proves that detailed preoperative evaluation, vigilant intraoperative monitoring, and adequate analgesia can lead to a smooth perioperative course for HCM patients for non-cardiac surgeries.

Automatic tablet-based monoplane quantification of stroke volume and left ventricular ejection fraction: A comparative assessment against computer-based biplane and monoplane tools

BACKGROUND

Point-of-care cardiovascular left ventricle ejection fraction (LVEF) quantification is established, but automatic tablet-based stroke volume (SV) quantification with handheld ultrasound (HAND) devices is unexplored. We evaluated a tablet-based monoplane LVEF and LV volume quantification tool (AutoEF) against a computer-based tool (Tomtec) for LVEF and SV quantification.

METHODS

Patients underwent HAND scans, and LVEF and SV were quantified using AutoEF and computer-based software that utilized either apical four-chamber views (Auto Strain-monoplane [AS-mono]) or both apical four-chamber and apical two-chamber views (Auto Strain-biplane [AS-bi]). Correlation and Bland-Altman analysis were used to compare AutoEF with AS-mono and AS-bi.

RESULTS

Out of 43 participants, eight were excluded. AutoEF showed a correlation of .83 [.69:.91] with AS-mono for LVEF and .68 [.44:.82] for SV. The correlation with AS-bi was .79 [.62:.89] for LVEF and .66 [.42:.81] for SV. The bias between AutoEF and AS-mono was 4.88% [3.15:6.61] for LVEF and 17.46 mL [12.99:21.92] for SV. The limits of agreement (LOA) were [-5.50:15.26]% for LVEF and [-8.02:42.94] mL for SV. The bias between AutoEF and AS-bi was 6.63% [5.31:7.94] for LVEF and 20.62 mL [16.18:25.05] for SV, with LOA of [-1.20:14.47]% for LVEF and [-4.71:45.94] mL for SV.

CONCLUSION

LVEF quantification with AutoEF software was accurate and reliable, but SV quantification showed limitations, indicating non-interchangeability with neither AS-mono nor AS-bi. Further refinement of AutoEF is needed for reliable SV quantification at the point of care.

Mechanical valve thrombosis: Current management and differences between guidelines

All foreign bodies inserted in the circulatory system are thrombogenic and require temporary or lifelong antithrombotic therapies to prevent thrombosis. The adequate level of anticoagulation during the first few months determines the long-term durability, particularly for mechanical prostheses, and also for biological valves. Suboptimal anticoagulation is the most frequent source of mechanical valve thrombosis (MVT). The patient's clinical presentation decides how mechanical prosthetic valve obstruction is managed. If the mechanical valve thrombosis is obstructive and the patient is in a critical condition with hemodynamic instability, an immediate surgical intervention should be performed. The thrombolytic treatment is an option for left mechanical valve thrombosis in patients who have high surgical risk and no contraindications and also for right heart valve thrombosis. In non-obstructive thrombosis on the mechanical valve, patients can be asymptomatic, requiring optimization of the anticoagulant treatment. Both obstructive and non-obstructive thrombus formed on the mechanical prosthesis can result in embolic events. If the thrombus persists following anticoagulant treatment, the recommended options include thrombolytic treatment or redo surgery. Pannus can also cause obstruction of the prosthesis for which surgical treatment is the only option. While these clinical scenarios may initially appear to have straightforward solutions in terms of surgery, thrombolysis, or effective anticoagulation, real-world clinical experience often proves more complex. For instance, a patient with some usual comorbidities and non-obstructive mechanical valve thrombosis, experiencing symptoms solely by repeated systemic embolizations, might undergo all three therapeutic options due to the unpredictable nature of MVT. Therefore, treatment indications can intersect both on the time axis and depending on the patient's clinical status and the expertise of the center where he is hospitalized. Moreover, the European and American guidelines show subtle but important differences. The aim of this review was to compare these differences, comment on recent studies and evidence gaps, propose a more pragmatic algorithm combining all current recommendations, and highlight important research directions for this disease that has dominated the cardiovascular landscape for more than five decades, but for which there have been no significant recent changes in management.

Leveraging emotional intelligence to foster proactive climate change adaptation: A study of engineering decision-making

The impacts of climate change and development present significant challenges and complexities that require new solutions, wise choices, and multi-disciplinary integration. In this context, emotional intelligence (EI) plays a crucial role. However, traditional engineering education and practice overlook the importance of understanding and managing emotions. This research aims to determine the impact of EI as a tool to enhance proactive decision-making and implement sustainable measures within the engineering profession.The study makes three main research contributions. First, it confirms a positive relationship between EI and proactive sustainable decision-making among engineers. This means that engineers with high EI are more likely to consider the impacts of their decisions on various stakeholders and dimensions of sustainability. Second, it suggests that EI can enhance creativity and innovative thinking in engineering, helping engineers to develop effective solutions for challenges related to climate change. Third, the study advocates for incorporating EI training and assessment into engineering curriculums to foster a sustainable and ethical engineering culture. By improving EI, engineers can enhance their interpersonal skills, self-awareness, and emotional management, which in turn can significantly improve teamwork in addressing challenges related to climate change.

Author Response: Oxygen Delivery Devices in Postoperative Patients: Proper Selection of Patients Matters!

How to cite this article: Mishra S, Kothari N, Sharma A, Goyal S. Author Response: Oxygen Delivery Devices in Postoperative Patients: Proper Selection of Patients Matters! Indian J Crit Care Med 2024;28(8):803.

Impacts of preoperative anxiety and depression on pain and range of motion after arthroscopic frozen shoulder release: a cohort study

PURPOSE

We aimed to evaluate the impact of preoperative anxiety and depression levels on baseline and postoperative pain in patients who underwent arthroscopic frozen shoulder release.

METHODS

The study included 59 patients with more than three months of idiopathic frozen shoulder. All patients had arthroscopic frozen shoulder release. Two patients were excluded from statistical analysis. Therefore, the statistical analysis was performed on the remaining 57 patients. The patients were divided into two groups according to HADS scores: group 1 which included 28 patients with a healthy psychological status (anxiety ≤ 7 and depression ≤ 7), and Group 2, which included 29 patients with psychological distress ( anxiety ≥ 8 or depression ≥ 8).

RESULTS

The hallmark finding of this study is that patients complaining of frozen shoulder symptoms and having psychological distress (HADS ≥ 8) experienced higher pain scores preoperatively and at one-year follow-up after arthroscopic release. All patients showed significant improvement between the preoperative period and the one year follow-up regarding the abduction, forward flexion, external rotation at the side and the VAS pain score with a P value of 0.001.

CONCLUSIONS

Arthroscopic frozen shoulder release significantly lowers the VAS pain score over the 12-month.

Pioglitazone reduces serum ketone bodies in sodium-glucose cotransporter-2 inhibitor-treated non-obese type 2 diabetes: A single-centre, randomized, crossover trial

AIM

To examine the effects of the thiazolidinedione (TZD) pioglitazone on reducing ketone bodies in non-obese patients with T2DM treated with the sodium-glucose cotransporter-2 (SGLT2) inhibitor canagliflozin.

METHODS

Crossover trials with two periods, each treatment period lasting 4 weeks, with a 4-week washout period, were conducted. Participants were randomly assigned in a 1:1 ratio to receive pioglitazone combined with canagliflozin (PIOG + CANA group) versus canagliflozin monotherapy (CANA group). The primary outcome was change (Δ) in β-hydroxybutyric acid (β-HBA) before and after the CANA or PIOG + CANA treatments. The secondary outcomes were Δchanges in serum acetoacetate and acetone, the rate of conversion into urinary ketones, and Δchanges in factors related to SGLT2 inhibitor-induced ketone body production including non-esterified fatty acids (NEFAs), glucagon, glucagon to insulin ratio, and noradrenaline (NA). Analyses were performed in accordance with the intention-to-treat principle.

RESULTS

Twenty-five patients with a mean age of 49 ± 7.97 years and a body mass index of 25.35 ± 2.22 kg/m2 were included. One patient discontinued the study during the washout period. Analyses revealed a significant increase in the levels of serum ketone bodies and an elevation in the rate of conversion into urinary ketones after both interventions. However, differernces in levels of ketone bodies (except for acetoacetate) in the PIOG + CANA group were significantly smaller than in the CANA group (219.84 ± 80.21 μmol/L vs. 317.69 ± 83.07 μmol/L, p < 0.001 in β-HBA; 8.98 ± 4.17 μmol/L vs. 12.29 ± 5.27 μmol/L, p = 0.018 in acetone). NEFA, glucagon, glucagon to insulin ratio, and NA were also significantly increased after both CANA and PIOG + CANA treatments; while only NEFAs demonstrated a significant difference between the two groups. Correlation analyses revealed a significant association between the difference in Δchanges in serum NEFA levels with the differences in Δchanges in ketones of β-HBA and acetoacetate.

CONCLUSION

Supplementation of pioglitazone could alleviate canagliflozin-induced ketone bodies. This benefit may be closely associated with decreased substrate NEFAs rather than other factors including glucagon, fasting insulin and NA.

Gait speed in knee osteoarthritis: A simple 10-meter walk test predicts the distance covered in the 6-minute walk test

BACKGROUND

The 6-Minute Walk Test (6MWT) is a common performance-measure in Knee Osteoarthritis (KOA), but the pain and functional impairment characterizing the condition may interfere its adequate performance.

OBJECTIVES

The shorter 10-m Walk Test (10mWT) could predict the distance performed on the 6MWT, therefore decreasing the burden on patients, enhancing efficiency, and reducing space- and time-constraints in clinical settings.

DESIGN

A cross sectional study was conducted.

METHODS

The scores from the 6MWT and the shorter 10mWT of 58 ambulatory subjects with KOA were compared. Correlation, and a univariate regression analysis to explore the predictive ability of the 10mWT, were calculated.

RESULTS

Correlation was excellent (r = 0.913, p-value<0.001), and the predictive equation based on the 10mWT scores (R2 = 0.834, p-value<0.001) estimates the distance walked in the 6MWT with a relative error of 7.62%.

CONCLUSIONS

The 10mWT may be an excellent assessment-tool to predict the distance walked in the 6MWT, due to its low strain on patients and as a means of improving efficiency and reducing time-constraints.

Cardioprotection in cardiovascular surgery

Since the invention of cardiopulmonary bypass, cardioprotective strategies have been investigated to mitigate ischemic injury to the heart during aortic cross-clamping and reperfusion injury with cross-clamp release. With advances in cardiac surgical and percutaneous techniques and post-operative management strategies including mechanical circulatory support, cardiac surgeons are able to operate on more complex patients. Therefore, there is a growing need for improved cardioprotective strategies to optimize outcomes in these patients. This review provides an overview of the basic principles of cardioprotection in the setting of cardiac surgery, including mechanisms of cardiac injury in the context of cardiopulmonary bypass, followed by a discussion of the specific approaches to optimizing cardioprotection in cardiac surgery, including refinements in cardiopulmonary bypass and cardioplegia, ischemic conditioning, use of specific anesthetic and pharmaceutical agents, and novel mechanical circulatory support technologies. Finally, translational strategies that investigate cardioprotection in the setting of cardiac surgery will be reviewed, with a focus on promising research in the areas of cell-based and gene therapy. Advances in this area will help cardiologists and cardiac surgeons mitigate myocardial ischemic injury, improve functional post-operative recovery, and optimize clinical outcomes in patients undergoing cardiac surgery.

Electrophysiological responses of audiovisual integration from infancy to adulthood

Our ability to merge information from different senses into a unified percept is a crucial perceptual process for efficient interaction with our multisensory environment. Yet, the developmental process underlying how the brain implements multisensory integration (MSI) remains poorly known. This cross-sectional study aims to characterize the developmental patterns of audiovisual events in 131 individuals aged from 3 months to 30 years. Electroencephalography (EEG) was recorded during a passive task, including simple auditory, visual, and audiovisual stimuli. In addition to examining age-related variations in MSI responses, we investigated Event-Related Potentials (ERPs) linked with auditory and visual stimulation alone. This was done to depict the typical developmental trajectory of unisensory processing from infancy to adulthood within our sample and to contextualize the maturation effects of MSI in relation to unisensory development. Comparing the neural response to audiovisual stimuli to the sum of the unisensory responses revealed signs of MSI in the ERPs, more specifically between the P2 and N2 components (P2 effect). Furthermore, adult-like MSI responses emerge relatively late in the development, around 8 years old. The automatic integration of simple audiovisual stimuli is a long developmental process that emerges during childhood and continues to mature during adolescence with ERP latencies decreasing with age.

Takotsubo syndrome after bilateral simultaneous total knee arthroplasty - A case report

Introduction

Cardiac complications represents a major cause of morbidity and mortality especially after bilateral simultaneous total knee arthroplasty (BS-TKA). Takotsubo syndrome after BS-TKA has not been described in the literature.

Case presentation

A 60 years-old women underwent BS- TKA and she suddenly developed bradycardia and hypotension after second knee wound closure. The electrocardiography revealed ST elevation and echocardiography showed apical hypokinesia of left ventricle. Coronary angiography revealed normal epicardial coronaries and a provisional diagnosis of Takotsubo cardiomyopathy was made. Serial ECGs revealed resolution of ST elevation and normal LV function within 5 days. On one-year follow up, she was able to do all her normal activities, and 12-lead electrocardiography were back to normal.

Conclusion

Cardiac complications represents a major cause of morbidity and mortality especially after BS-TKA. Surgeons must be vigilant in the postoperative period for any likely precipitating factors of stress induced cardiomyopathy. Takotsubo syndrome should be considered as a differential diagnosis with features of acute coronary syndrome in elderly post-menopausal patients.

Successful bilateral lung transplantation in a five-year-old child with pulmonary interstitial fibrosis caused by an ABCA3 gene mutation

The ATP-binding cassette subfamily A member 3 (ABCA3) protein plays a fundamental role in surfactant homeostasis. Most children with ABCA3 gene mutations develop pulmonary interstitial fibrosis leading to the development of interstitial lung disease. Since traditional medicine does not offer effective therapy, the best option is lung transplantations, especially bilateral lung transplantations. We are reporting the case of a successful bilateral lung transplantation in a five-year-old child with pulmonary interstitial fibrosis caused by ABCA3 gene mutations. This successful transplantation enabled the patient to get rid of chronic cough and tachypnea.

Comparing different postoperative sedation strategies for patients in the intensive care unit after cardiac surgery: A systematic review of randomized controlled trials and network meta-analysis

BACKGROUND

Various postoperative sedation protocols with different anaesthetics lead to profound effects on the outcomes for post-cardiac surgery patients. However, a comprehensive analysis of optimal postoperative sedation strategies for patients in the intensive care unit (ICU) after cardiac surgery is lacking.

METHODS

We systematically searched for randomized controlled trials (RCTs) in databases including PubMed and Embase. The primary outcome measured the duration of mechanical ventilation (MV) in the ICU, and the secondary outcome encompassed the length of stay (LOS) in the ICU and hospital and the monitoring adverse events.

RESULTS

The literature included 18 RCTs (1652 patients) with 13 sedation regimens. Dexmedetomidine plus ketamine and sevoflurane were associated with a significantly reduced duration of MV when compared with propofol. Our results also suggested that dexmedetomidine plus ketamine may associated with a shorter LOS in ICU, and sevoflurane associated with a shorter LOS in the hospital, respectively.

CONCLUSIONS

The combination of dexmedetomidine and ketamine seems to be a better option for adult patients needing sedation after cardiac surgery, and the incidence of side effects is lower with dexmedetomidine. These findings have potential implications for medication management in the perioperative pharmacotherapy of cardiac surgery patients.

The involvement of rTPJ in intention attribution during social decision making: A TMS study

The mini-Ultimatum Game (mini-UG) is a bargaining game used to assess the reactions of a responder to unfair offers made by a proposer under different intentionality conditions. Previous studies employing this task showed the activation of responders' right temporoparietal junction (rTPJ), which could be related to its involvement in judgments of intentionality. To verify this hypothesis, in the present study we applied online transcranial magnetic stimulation (TMS) over the rTPJ in responders during the mini-UG, in which we manipulated intention attribution implicitly. A cover story was employed to induce participants to believe they were interacting with another agent. We expected that interfering with the rTPJ could affect the ability of responders to assume proposers' perspective, producing higher rates of rejections of unfair offers when offers are perceived as independent from responders' intentionality to inequality. Twenty-six healthy women voluntarily participated in the study. In the mini-UG, an unfair distribution of the proposer (8/2 offer) was pitted against one of three alternative offers: fair-alternative (5/5), no-alternative (8/2), hyperfair-alternative (2/8). During the task, a train of TMS pulses was delivered at proposers' offer presentation in blocks of active (rTPJ) or control (Vertex) stimulation according to an ABAB design. As expected, findings showed that rejection of the no-alternative offers was higher under TMS stimulation of the rTPJ compared with the control TMS. This effect was modulated by the degree of trustworthiness in the cover story. These data contribute defining the mechanisms and brain areas underpinning social decision making as assessed by bargaining tasks.

Successful treatment of acute device thrombosis of patent foramen ovale with slow infusion of low-dose thrombolytic therapy

Background

Percutaneous closure of patent foramen ovale (PFO) is used in selected individuals to eliminate the risk of recurrent cerebral embolism due to paradoxical embolization. Although device thrombosis is rare, it can cause serious complications. Herein, we report a 40-year-old woman who developed acute PFO closure device-associated thrombus and was subsequently treated with slow infusion of low-dose tissue plasminogen activator (t-PA) (25 mg/6 h).

Case summary

A 40-year-old woman was admitted to the hospital because of an cerebrovascular accident (CVA). Computed tomography and magnetic resonance imaging of the brain demonstrated the presence of an ischaemic lesion in the right cerebellar infarct. Since no pathological finding was detected that could cause CVA, it was considered that there might be paradoxical embolism due to PFO. Percutaneous PFO closure was decided by the heart and brain team. The occluder was implanted under transoesophageal echocardiography (TEE) and fluoroscopy guidance. Although activated clotting time was 250 s, hypermobile acute thrombus measuring 11 × 5 mm was seen on the left atrial side of the PFO device. Slow infusion of low-dose t-PA treatment was given. As soon as after a single-dose t-PA, control TEE was performed and it was seen that almost the entire thrombus was lysed. The patient did not have any complications during the treatment period.

Discussion

Acute PFO device thrombosis is a rare but important complication. If there is no contraindication for lytic treatment in acutely developing large PFO device thrombosis, slow infusion of low-dose t-PA may be useful.

Strategies for the Management of Cardiorenal Syndrome in the Acute Hospital Setting

Cardiorenal syndrome (CRS) is a life-threatening disorder that involves a complex interplay between the two organs. Managing this multifaceted syndrome is challenging in the hospital and requires a multidisciplinary approach to tackle the many manifestations and complications. There is no universally accepted algorithm to treat patients, and therapeutic options vary from one patient to another. The mainstays of therapy involve the stabilization of hemodynamics, decongestion using diuretics or renal replacement therapy, improvement of cardiac output with inotropes, and goal-directed medical treatment with renin–angiotensin–aldosterone system inhibitors, beta-blockers, and other medications. Mechanical circulatory support is another viable option in the armamentarium of agents that improve symptoms in select patients.

Congenital diaphragmatic hernia-associated pulmonary hypertension

Congenital diaphragmatic hernia (CDH) is characterized by a developmental insult which compromises cardiopulmonary embryology and results in a diaphragmatic defect, allowing abdominal organs to herniate into the hemithorax. Among the significant pathophysiologic components of this condition is pulmonary hypertension (PH), alongside pulmonary hypoplasia and cardiac dysfunction. Fetal pulmonary vascular development coincides with lung development, with the pulmonary vasculature evolving alongside lung maturation. However, in CDH, this embryologic development is impaired which, in conjunction with external compression, stifle pulmonary vascular maturation, leading to reduced lung density, increased muscularization of the pulmonary vasculature, abnormal vascular responsiveness, and altered molecular signaling, all contributing to pulmonary arterial hypertension. Understanding CDH-associated PH (CDH-PH) is crucial for development of novel approaches and effective management due to its significant impact on morbidity and mortality. Antenatal and postnatal diagnostic methods aid in CDH risk stratification and, specifically, pulmonary hypertension, including fetal imaging and gas exchange assessments. Management strategies include lung protective ventilation, fluid optimization, pharmacotherapies including pulmonary vasodilators and hemodynamic support, and extracorporeal life support (ECLS) for refractory cases. Longitudinal re-evaluation is an important consideration due to the complexity and dynamic nature of CDH cardiopulmonary physiology. Emerging therapies such as fetal endoscopic tracheal occlusion and pharmacological interventions targeting key CDH pathophysiological mechanisms show promise but require further investigation. The complexity of CDH-PH underscores the importance of a multidisciplinary approach for optimal patient care and improved outcomes.

Cardiac interventricular septum hemangioma in a colon cancer patient treated with Capecitabine: A case report and review of literature

We report a case of a 21-year-old male with stage IIIB sigmoid colon adenocarcinoma who experienced atypical chest pain post-adjuvant chemotherapy with Capecitabine (5-FU prodrug). Evaluation revealed an unexpectedly detected interventricular septum hemangioma. Due to the vasospasm effect of chemotherapy presenting with semi-ischemia, conservative management was chosen for atypical presentation.

Factors related to the disaster preparedness of patients on haemodialysis from Sichuan, China, during COVID-19: A cross-sectional study

AIM

This study aimed to investigate personal preparedness among patients on haemodialysis (HD) and to examine the relationship among sociodemographic characteristics, attitudes toward disaster preparedness and personal preparedness behaviours during natural disaster incidents.

DESIGN

A cross-sectional survey was conducted.

METHODS

A convenience sampling method was used. A total of 446 participants from six areas of Sichuan province completed the online questionnaire study from February 27 to March 13, 2022. Sociodemographic characteristics, attitudes toward disaster preparedness and personal preparedness behaviours were measured. Descriptive statistics were used to analyse sociodemographic characteristics and attitudes toward disaster preparedness. The relationship among sociodemographic characteristics, attitudes toward disaster preparedness and personal preparedness behaviours were assessed using ordinal regression. Statistical significance was defined as p < 0.05.

RESULTS

A total of 446 participants completed the survey. Of these, 42.15% (N = 188) were poorly prepared, 26.23% (N = 117) were moderately prepared and 31.61% (N = 141) were highly prepared. Ordinal regression showed that knowing about disaster preparedness (Odds Ratio (OR) = 1.691, 95% Confidence Interval (CI) = 1.081-2.644, p = 0.021), participating in disaster evacuation exercises (OR = 2.519, 95% CI = 1.595-3.977, p < 0.001) and learning about disaster preparedness (OR = 2.421, 95% CI = 1.542-3.802, p < 0.001) were associated with high preparedness. Compared to patients with a university degree or higher, patients with a junior high school education or lower (OR = 3.491, 95% CI = 1.760-6.925, p < 0.001) and senior high school degree (OR = 2.052, 95% CI = 1.038-4.057, p = 0.039) were associated with high preparedness. Patients who felt very confident and could deal with all their needs (OR = 3.878, 95% CI = 2.904-7.181, p < 0.001) or patients who felt confident and could meet some of their needs (OR = 1.949, 95% CI = 1.124-3.379, p = 0.017) had higher preparedness than those who felt less confident and were not well prepared to take care of their needs.

PATIENT OR PUBLIC CONTRIBUTION

After obtaining each participant's consent, they filled out the online questionnaire using their own or a relative's cell phone while undergoing HD.

IMPLICATION FOR PRACTICE

It is essential that patients should be educated not only on medical specialty topics, but also on general disaster preparedness. Medical institutions should improve and reinforce preparation training among targeted populations. The low level of preparedness is partly due to the lack of participation of patients in disaster preparedness programs. Dialysis center managers should be urged to implement such programs at their centers.

Patient dose and associated exposure parameters in pelvic x-ray examinations: dependence on radiographic system

Technological differences between computed radiography (CR) and digital radiography (DR) systems can influence patient doses and exposure parameters in pelvic x-ray examinations. The presence of radiosensitive organs in the pelvic region underscores the need to optimize these parameters for both CR and DR systems. This prospective study aimed to compare the patient doses and exposure parameters for adult patients undergoing pelvic x-ray examinations using CR and DR systems, based on data from Sri Lanka. The study included data from 56 x-ray examinations, with 25 using CR and 31 using DR. Patient demographic characteristics and exposure parameters (kVp: kilovoltage peak, mAs: tube current-exposure time product) were recorded, and patient doses were measured in terms of the kerma-area product (PKA) using a PKA meter. Despite similar mean weight and body mass index (BMI), the CR systems showed significantly higher mean kVp (7.4%), mAs (16.4%), and PKA (29.7%) than the DR systems (CR - kVp: 73.2, mAs: 37.8, PKA: 2.29 Gy cm2; DR - kVp: 67.8, mAs: 31.6, PKA: 1.61 Gy cm2). The Mann-Whitney U test revealed statistically significant differences in PKA and kVp between the CR and DR systems (p < 0.05). Furthermore, even with lower patient weight and BMI, the mean mAs and PKA in this study were substantially higher than those reported in the literature for both CR and DR systems. These results suggest the need to optimize current mAs settings for the studied hospitals and introduce radiographic system-specific exposure parameters and reference dose levels for pelvic x-ray examinations in order to enhance patient protection.

Brugada Syndrome: Anesthetic Implications in an Incidentally Diagnosed Patient

Brugada syndrome (BS) is characterized by abnormal repolarization in cardiac cells, occurring in the absence of structural heart disease, which elevates the risk of ventricular arrhythmias and sudden cardiac death. While most BS patients are asymptomatic, a notable percentage experience syncope or sudden cardiac death. Diagnosis is primarily based on electrocardiographic (ECG) findings. A 40-year-old male with a history of syncope and a family history of sudden cardiac death was scheduled for urgent clavicle osteosynthesis. Preoperative ECG revealed type 1 BS. A multidisciplinary approach was taken, and anesthetic management involved combined general and regional anesthesia, utilizing ultrasound-guided clavipectoral and superficial cervical blocks. Postoperative pain was managed with paracetamol and ketorolac. The patient remained stable throughout the procedure, was monitored for 36 hours postoperatively, and was discharged without complications. BS poses significant perioperative risks, necessitating careful anesthetic management. This case report highlights the successful use of combined general and regional anesthesia in a BS patient, contributing to the limited evidence on safe anesthesia practices for this pathology.

Histidine-Tryptophan-Ketoglutarate Cardioplegia Yields Different Results in Aortic Valve Surgery Depending on Patient Gender: A Pilot Study

BACKGROUND

Histidine-tryptophan-ketoglutarate (HTK) cardioplegia induces cardiac arrest through membrane hyperpolarization. Aortic valve pathology leads to pathophysiological changes in left ventricular vascularization that may prevent adequate cardioplegic distribution. The objective of the study was to ascertain whether the use of Bretschneider cardioplegia in aortic valve surgery yields different outcomes for male and female patients.

METHODOLOGY

Our study compares the perioperative data of 300 adult patients who underwent aortic valve replacement between June 2023 and June 2024 at the Emergency Cardiac Disease and Transplant Institute, Tîrgu Mures, Romania. Concomitant procedures, age under 18 years, retrograde or combined cardioplegia, and emergency surgery were excluded. The main outcome was operative mortality, and secondary outcomes were postoperative complications and paraclinical data such as ejection fraction and cardiac enzymes.

RESULTS

Male patients comprised 190 (62%) of the sample. The most common age group was 61-70 years in both groups. The mortality rate was 6 (5.4%) for women compared to 9 (4.7%) for men. Preoperative left ventricular ejection fraction was the primary covariate determining 30-day postoperative mortality. Left ventricular ejection fraction decreased by 2.2% in men and 1.1% in women 30 days after surgery.

CONCLUSIONS

The myocardial adaptation to aortic valve pathology exhibits gender-specific differences. However, the utilization of HTK cardioplegia obviates this disparity.