Pain trajectories and neuropathic pain symptoms following lung cancer surgery: A prospective cohort study

BACKGROUND

Persistent postsurgical pain (PPSP) after lung cancer surgery is common and current definitions are based on evaluations at a single time point after surgery. Pain intensity and symptoms may however fluctuate and change over time, and be impacted by multiple and shifting factors. Studies of postoperative recovery patterns and transition from acute to chronic pain are needed for further investigation of preventive measures and treatments to modify unfavourable recovery paths.

METHODS

In this explorative study, 85 patients undergoing surgery due to either presumptive or confirmed lung cancer reported pain intensities bi-monthly for 12 months. Pain trajectories during recovery were investigated, using group-based trajectory modelling. Associations with possible risk factors for PPSP, including clinical variables and anxiety and depression score (HADS), were also explored.

RESULTS

A trajectory model containing three 12-month pain recovery groups was computed. One group without PPSP fully recovered (50%) within two to three months. Another group with mild-intensity PPSP followed a protracted recovery trajectory (37%), while incomplete recovery was observed in the last group (13%). Acute postoperative pain and younger age were associated with a less favourable recovery trajectory. More neuropathic pain symptoms were observed in patients with incomplete recovery.

CONCLUSIONS

Three clinically relevant recovery trajectories were identified, based on comprehensive pain tracking. Higher acute postoperative pain intensity was associated with an unfavourable pain recovery trajectory.

SIGNIFICANCE STATEMENT

Understanding the transition from acute to chronic postoperative pain and identifying preoperative risk factors is essential for the development of targeted treatments and the implementation of preventive measures. This study (1) identified distinct recovery trajectories based on frequent pain assessment follow-ups for 12 months after surgery and (2) evaluated risk factors for unfavourable postoperative pain recovery paths. Findings suggest that early higher postoperative pain intensity is associated with an unfavourable long-term recovery path.

Exercise-based real-time telerehabilitation for older patients recently discharged after transcatheter aortic valve implantation: An extended feasibility study

OBJECTIVES

To assess the extended feasibility of a telerehabilitation program and its effects on physical performance in older adults who have recently undergone transcatheter aortic valve implantation (TAVI).

METHODS

In this single-center feasibility study, patients underwent an eight-week telerehabilitation program, involving web-based home exercise training twice weekly, an activity tracker, access to an informative website, and one online session with a nurse, starting one-week postoperative. Data collection was performed before surgery and three months postoperative. The feasibility of the intervention was based on recruitment and adherence to the program. As a secondary outcome, we evaluated the change in six-minute walk distance from before surgery to three months postoperative.

RESULTS

Forty-one patients scheduled for TAVI were assessed for eligibility; 15 patients (37%) were enrolled. Of these, eight were excluded after surgery due to tiredness (n = 2), non-cardiac related hospital readmission (n = 2), fluctuating health (n = 1), death during hospital stay (n = 1), and reduced cognition (n = 2). Seven patients completed the eight-week web-based intervention and were evaluated three months postoperative. Their median (IQR) age was 83 [81, 87] years, and the sample comprised three men and four women. Their walked distance improved from median (IQR) 262 [199, 463] before surgery, to 381 [267, 521] meters three months postoperative. No adverse events were reported.

CONCLUSION

Web-based telerehabilitation, including supervised exercise training, in older adults who have recently undergone TAVI was feasible for a small number of patients who completed the eight-week intervention. This was reflected in an improvement in their walked distance three months after the surgery. However, the low recruitment and retention rates do question the overall feasibility of this intervention in a frail, older population of post-TAVI patients.

Postponement of elective cardiac surgery: A prospective observational analysis of anxiety, depression, social support and clinical complications

AIMS

To investigate patients' psychological reactions to postponement of elective cardiac surgery, and whether postponement was associated with increased complications post-operative and while waiting.

DESIGN

A single-centre observational prospective cohort study.

METHODS

All adult patients referred for elective cardiac surgery during the study period were considered for inclusion. Psychological data were collected using a survey distributed to patients prior to surgery and at 6 months post-operative. Clinical data were obtained from patient records.

RESULTS

A total of 83 postponed and 132 non-postponed patients were included. Postponed patients displayed more avoidance behaviour, but only immediately before surgery. Postponed patients maintained their satisfaction with perceived social support, whereas non-postponed patients became more dissatisfied over time. Waiting 0-14 days was associated with increased symptoms of depression before surgery compared to non-postponed patients or those waiting more than 14 days. Surgical complications were the same in both groups. No patients experienced aggravation of their disease leading to urgent or emergent surgery while waiting for surgery. Hospital-related reasons were the most common cause for postponement of surgery.

CONCLUSION

Postponement of selected patients is not associated with increased risk of psychological distress or complications related to the patient's disease.

REPORTING METHOD

Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

IMPLICATIONS FOR PATIENT CARE

Pre- and post-psychological interventions may be relevant to consider in relation to elective cardiac surgery as it has been shown to positively affect outcome. Organisational/hospital-related reasons are still very common causes for postponement of elective surgeries, and hospital administrations should focus upon eliminating/decreasing this.

PUBLIC CONTRIBUTION

Questionnaires filled by patients were used to understand an association between postponement of cardiac surgery and psychological distress.

Chronic post-thoracotomy pain after lung cancer surgery: a prospective study of preoperative risk factors

OBJECTIVES

The objective of this longitudinal cohort study was to investigate if preoperative pain mechanisms, anxiety, and depression increase risk of developing chronic post-thoracotomy pain (CPTP) after lung cancer surgery.

METHODS

Patients with suspected or confirmed lung cancer undergoing surgery by either video-assisted thoracoscopic surgery or anterior thoracotomy were recruited consecutively. Preoperative assessments were conducted by: quantitative sensory testing (QST) (brush, pinprick, cuff pressure pain detection threshold, cuff pressure tolerance pain threshold, temporal summation and conditioned pain modulation), neuropathic pain symptom inventory (NPSI), and the Hospital Anxiety and Depression Scale (HADS). Clinical parameters in relation to surgery were also collected. Presence of CPTP was determined after six months and defined as pain of any intensity in relation to the operation area on a numeric rating scale form 0 (no pain) to 10 (worst pain imaginable).

RESULTS

A total of 121 patients (60.2 %) completed follow-up and 56 patients (46.3 %) reported CPTP. Development of CPTP was associated with higher preoperative HADS score (p=0.025), higher preoperative NPSI score (p=0.009) and acute postoperative pain (p=0.042). No differences were observed in relation to preoperative QST assessment by cuff algometry and HADS anxiety and depression sub-scores.

CONCLUSIONS

High preoperative HADS score preoperative pain, acute postoperative pain intensity, and preoperative neuropathic symptoms were was associated with CPTP after lung cancer surgery. No differences in values of preoperative QST assessments were found. Preoperative assessment and identification of patients at higher risk of postoperative pain will offer opportunity for further exploration and development of preventive measures and individualised pain management depending on patient risk profile.

Less transfusion is still more-red blood cell transfusion affects long-term mortality in cardiac surgery

OBJECTIVE

Previous studies indicated higher long-term mortality after the transfusion of allogeneic red blood cells and newer recommendations emphasize lower transfusion rates. Consequences of transfusion of red blood cells in cardiac surgery are unclear, as later studies focused on transfusion triggers and short-term outcomes and reports on long-term complications after cardiac surgery are few.

MATERIAL AND METHODS

The mandatory Western Denmark Heart Registry was used to identify all adult cardiac surgeries performed in four centres from 2000-2019. Patients with multiple entries or previous cardiac surgery, special/complex procedures, dying within 30 days and not eligible for follow-up were excluded.

RESULTS

A total of 32,581 adult cardiac surgeries performed in four centres from 2000-2019 were included. The Kaplan-Meier survival plot for low-risk patients undergoing simple cardiac surgery showed a significantly lower 15-year survival (0.384 vs 0.661) when receiving perioperative red blood cell transfusion (OR 2.43 (CL 2.23-2.66)). The risk decreased with increasing comorbidity or age, and in high-risk patients, no difference was found. The adjusted risk ratio, after RBC transfusion, including age, sex, comorbidity and surgery, was 1.62 (1.48-1.77).

CONCLUSION

Despite reduced transfusion rates, long-term follow-up on especially low-risk patients undergoing comparable cardiac surgery still demonstrates a substantially higher mortality in patients receiving perioperative red blood cell transfusion. Even transfusion of 1-2 units is associated with increased long-term mortality.

Exercise-Based Real-time Telerehabilitation for Older Adult Patients Recently Discharged After Transcatheter Aortic Valve Implantation: Mixed Methods Feasibility Study

BACKGROUND

The use of telehealth technology to improve functional recovery following transcatheter aortic valve implantation (TAVI) has not been investigated.

OBJECTIVE

In this study, we aimed to examine the feasibility of exercise-based cardiac telerehabilitation after TAVI.

METHODS

This was a single-center, prospective, nonrandomized study using a mixed methods approach. Data collection included testing, researchers' observations, logbooks, and individual patient interviews, which were analyzed using a content analysis approach. The intervention lasted 3 weeks and consisted of home-based web-based exercise training, an activity tracker, a TAVI information website, and 1 web-based session with a nurse.

RESULTS

Of the initially included 13 patients, 5 (40%) completed the study and were interviewed; the median age was 82 (range 74-84) years, and the sample comprised 3 men and 2 women. Easy access to supervised exercise training at home with real-time feedback and use of the activity tracker to count daily steps were emphasized by the patients who completed the intervention. Reasons for patients not completing the program included poor data coverage, participants' limited information technology skills, and a lack of functionality in the systems used. No adverse events were reported.

CONCLUSIONS

Exercise-based telerehabilitation for older people after TAVI, in the population as included in this study, and delivered as a web-based intervention, does not seem feasible, as 60% (8/13) of patients did not complete the study. Those completing the intervention highly appreciated the real-time feedback during the web-based training sessions. Future studies should address aspects that support retention rates and enhance patients' information technology skills.

Patient and health professional perspectives on participations in a feasibility study on exercise-based cardiac telerehabilitation after transcatheter aortic valve implantation: A qualitative study. (Preprint)

Background

Aortic valve stenosis affects approximately half of people aged ≥85 years, and the recommended surgical treatment for older patients is transcatheter aortic valve implantation (TAVI). Despite strong evidence for its advantages, low attendance rate in cardiac rehabilitation is observed among patients after TAVI. Cardiac telerehabilitation (CTR) has proven comparable with center-based rehabilitation; however, no study has investigated CTR targeting patients after TAVI. On the basis of participatory design, an exercise-based CTR program (TeleTAVI) was developed, which included a web-based session with a cardiac nurse, a tablet containing an informative website, an activity tracker, and supervised home-based exercise sessions that follow the national recommendations for cardiac rehabilitation.

Objective

This study aims to explore patients’ and health professionals’ experiences with using health technologies and participating in the exercise-based CTR program, TeleTAVI.

Methods

This study is a part of a feasibility study and will only report patients’ and health professionals’ experiences of being a part of TeleTAVI. A total of 11 qualitative interviews were conducted using a semistructured interview guide (n=7, 64% patients and n=4, 36% health professionals). Patient interviews were conducted after 8 weeks of participation in TeleTAVI, and interviews with health professionals were conducted after the end of the program. The analysis was conducted as inductive content analysis to create a condensed meaning presented as themes.

Results

Reticence toward using the website was evident with reduced curiosity to explore it, and reduced benefit from using the activity tracker was observed, as the patients’ technical competencies were challenged. This was also found when using the tablet for web-based training sessions, leading to patients feeling worried before the training, as they anticipated technical problems. Disadvantages of the TeleTAVI program were technical problems and inability to use hands-on guidance with the patients. However, both physiotherapists and patients reported a feeling of improvement in patients’ physical fitness. The home training created a feeling of safety, supported adherence, and made individualization possible, which the patients valued. A good relationship and continuity in the contact with health professionals seemed very important for the patients and affected their positive attitude toward the program.

Conclusions

The home-based nature of the TeleTAVI program seems to provide the opportunity to support individualization, autonomy, independence, and adherence to physical training in addition to improvement in physical capability in older patients. Despite technological challenges, basing the relationship between the health professionals and patients on continuity may be beneficial for patients. Prehabilitation may also be considered, as it may create familiarity toward technology and adherence to the training.

Distress and anxiety following postponed cardiac surgery prior to and during the COVID-19 pandemic

INTRODUCTION

Recently, the COVID-19 pandemic has caused postponements of elective cardiac surgery. We hypothesised that postponements due to the pandemic were associated with higher levels of psychological distress than prepandemic postponements.

METHODS

A prospective, observational cohort study was conducted among patients in whom elective cardiac surgery was postponed. Patients who received information regarding a new date of surgery prior to the pandemic were compared with patients postponed during the pandemic without information regarding a new date of surgery. Data were collected from patient records, validated questionnaires and interviews.

RESULTS

Out of 55 postponed patients, 21 experienced prepandemic postponement. No significant differences were observed between groups regarding the psychological measures before their rescheduled operation. However, patients in both groups reported high levels of anxiety and depression with > 60% indicative of potentially positive diagnoses. No differences were found in mortality across groups and no patients developed severe complications. Interviews showed that patients in the COVID-19 group felt immediate relief at postponement and engaged in a meaning-making process with respect to their ability to tolerate postponement in order to reassure themselves and their relatives.

CONCLUSIONS

No significant differences were found in psychological distress between the patients of the two groups. However, both groups experienced high levels of psychological distress. It remains unknown whether these results may be extrapolated to other surgical fields.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Health-Related Quality of Life and Angina in Fractional Flow Reserve- Versus Angiography-Guided Coronary Artery Bypass Grafting: FARGO Trial (Fractional Flow Reserve Versus Angiography Randomization for Graft Optimization)

BACKGROUND

In coronary artery bypass grafting (CABG), the use of fractional flow reserve (FFR) is insufficiently investigated. Stenosis assessment usually relies on visual estimates of lesion severity. This study evaluated health-related quality of life (HRQoL) and angina after FFR- versus angiography-guided CABG.

METHODS

One hundred patients referred for CABG were randomized to FFR- or angiography-guided CABG. In the FFR group, lesions with FFR>0.80 were deferred, while the surgeon was blinded to the FFR values in the angiography group. Before and 6 months after CABG, HRQoL was assessed by the health state classifier EQ-5D of the EuroQoL 5-level instrument and angina status based on the Canadian Cardiovascular Society classification system were registered.

RESULTS

Six-month angiography included FFR evaluations of deferred lesions. In total, completed EQ-5D of the EuroQoL 5-level instrument questionnaires were available in 86 patients (43 in the FFR versus 43 in the angiography-guided group). HRQoL was significantly improved and angina significantly decreased from baseline to 6 months after CABG with no difference between the randomization groups. Graft failure rates and clinical outcomes were similar in both groups. Patients with graft failure or FFR<0.80 of the previous deferred lesions had significantly lower visual analogue scale scores (78.7±14.2 versus 86.8±14.7, P=0.004) and more angina compared with patients without graft failure or FFR≥0.80 at 6-month follow-up.

CONCLUSIONS

FFR- versus angiography-guided CABG demonstrated similar improvements in HRQoL and angina 6 months after CABG. Graft failure or low FFR in deferred lesions were associated with low HRQoL and angina. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02477371.

Metabolic changes during carbon monoxide poisoning: An experimental study

Carbon monoxide (CO) is the leading cause of death by poisoning worldwide. The aim was to explore the effects of mild and severe poisoning on blood gas parameters and metabolites. Eleven pigs were exposed to CO intoxication and had blood collected before and during poisoning. Mild CO poisoning (carboxyhaemoglobin, COHb 35.2 ± 7.9%) was achieved at 32 ± 13 minutes, and severe poisoning (69.3 ± 10.2% COHb) at 64 ± 23 minutes from baseline (2.9 ± 0.5% COHb). Blood gas parameters and metabolites were measured on a blood gas analyser and nuclear magnetic resonance spectrometer, respectively. Unsupervised principal component, analysis of variance and Pearson's correlation tests were applied. A P-value ≤ .05 was considered statistically significant. Mild poisoning resulted in a 28.4% drop in oxyhaemoglobin (OHb) and 12-fold increase in COHb, while severe poisoning in a 65% drop in OHb and 24-fold increase in COHb. Among others, metabolites implicated in regulation of metabolic acidosis (lactate, P < .0001), energy balance (pyruvate, P < .0001; 3-hydroxybutyrc acid, P = .01), respiration (citrate, P = .007; succinate, P = .0003; fumarate, P < .0001), lipid metabolism (glycerol, P = .002; choline, P = .0002) and antioxidant-oxidant balance (glutathione, P = .03; hypoxanthine, P < .0001) were altered, especially during severe poisoning. Our study adds new insights into the deranged metabolism of CO poisoning and leads the way for further investigation.

Peroperative epicardial ultrasonography of distal coronary artery bypass graft anastomoses using a stabilizing device. A feasibility study

Background

Widespread use of intraoperative epicardial ultrasonography (ECUS) for quality assessment of coronary artery bypass graft anastomoses during coronary artery bypass grafting (CABG) has not occurred - presumably due to technological and practical challenges including the need to maintain stable and optimal acoustic contact between the ultrasound probe and the target without the risk of distorting the anastomosis. We investigated the feasibility of using a stabilizing device during ultrasound imaging of distal coronary bypass graft anastomoses in patients undergoing on-pump CABG. Imaging was performed in both the longitudinal and transverse planes.

Methods

Single-centre, observational prospective feasibility study among 51 patients undergoing elective, isolated on-pump CABG. Ultrasonography of peripheral coronary bypass anastomoses was performed using a stabilizing device upon which the ultrasound transducer was connected. Transit-time flow measurement (TTFM) was also performed. Descriptive statistical tests were used.

Results

Longitudinal and transverse images from the heel, middle and toe were obtained from 134 of 155 coronary anastomoses (86.5%). After the learning curve (15 patients), all six projections were obtained from 100 of 108 anastomoses scanned (93%). Failure to obtain images were typical due to a sequential curved graft with anastomoses that could not be contained in the straight cavity of the stabilizing device, echo artefacts from a Titanium clip located in the roof of the anastomoses, and challenges in interpreting the images during the learning curve. No complications were associated with the ECUS procedure. The combined ECUS and TTFM resulted in immediate revision of five peripheral anastomoses.

Conclusions

Peroperative use of a stabilizing device during ultrasonography of coronary artery bypass anastomoses in on-pump surgery facilitates imaging and provides surgeons with non-deformed longitudinal and transverse images of all parts of the anastomoses in all coronary territories. Peroperative ECUS in addition to flow measurements has the potential to increase the likelihood of detecting technical errors in constructed anastomoses.

Trial registration

The study was registered on September 29, 2016, ClinicalTrials.gov ID: NCT02919124.

Effect of Atrial Septal Defect in Adults on Work Participation (from a Nation Wide Register-Based Follow-Up Study Regarding Work Participation and Use of Permanent Social Security Benefits)

Low work participation is well known in patients with chronic disease but has not been described in patients with atrial septal defect (ASD). In this nation-wide cohort study, we report the first long-term follow-up of use of permanent social security benefits and work participation in adults with ASD. All Danes born before 1994 and diagnosed with ASD from 1959 to 2013 (n = 2,277) were identified from the Danish medical registries. We used Cox proportional hazards regression to compare the risk of receiving permanent social security benefits in the ASD patients compared with an age- and gender-matched general population cohort. Using the DREAM database, we calculated work participation score and proportion of patients working or not working at the age of 30 years. Median follow-up from ASD diagnosis was 23.4 years (range 0.2 to 59.3). ASD patients had a higher risk of receiving permanent social security benefits (hazard ratio 2.3 [95% confidence interval 2.1 to 2.6]) compared with the comparison cohort with 24% of the ASD patients receiving permanent social security benefits at the end of follow-up compared with 12% of the comparison cohort. At the age of 30 years, the proportion not working was 28% in the ASD cohort and 18% in the comparison cohort. In patients with ASD, 23% of those without a job had a psychiatric diagnosis. In conclusion, the risk of receiving permanent social security benefits was twice as high in patients with ASD and the work participation score was reduced compared with the background population.

Socioeconomic consequences for adults with atrial septal defect: A register based follow-up study

Background

Atrial Septal Defect (ASD) is considered one of the most benign defects among congenital heart disease. The very good short and midterm outcomes after closure in the recent decades has led to believe that the ASD population is almost comparable to the background population after treatment. However, recent studies indicate that these patients are much more affected by their disease than first assumed. In this nationwide cohort study, we report the first long-term follow-up of use of permanent social security benefits and work participation in adults with ASD.

Methods

All Danish patients born before 1994 and diagnosed with ASD between 1959-2013 (n = 2,277) were identified from the Danish registries. A comparison cohort was created using the Danish Civil Registration System, matching every verified ASD patient with 10 persons from the general population on gender and birth year. We used Cox proportional hazards regression to compare the risk of receiving permanent social security benefits in the ASD patients compared with the matched cohort. Using the DREAM database we calculated the proportion of patients and controls not working at the age of 30 years.

Results

ASD patients had a higher risk of receiving permanent social security benefits (hazard ratio 2.3 (95% confidence interval 2.1-2.6)) compared with the comparison cohort; 24% of the ASD patients was receiving permanent social security benefits at the end of follow up compared with 12% of the comparison cohort. At the age of 30 years, the proportion not working was 28% in the ASD cohort and 18% in the comparison cohort. Of patients not working 23% had a psychiatric diagnose compared to 6.8% of the controls.

Conclusions

The risk of receiving permanent social security benefits was twice as high in patients with ASD and the work participation was reduced compared with the background population.

Key messages

The poor affiliation to the work force and high prevalence of psychiatric morbidity is worrying. It demands for an increased psychosocial support by professionals caring for patients with ASD.

Integration of Rehabilitation Activities Into Everyday Life Through Telerehabilitation: Qualitative Study of Cardiac Patients and Their Partners

Background

Implementation of cardiac rehabilitation has not been optimal, with patient participation rates below 50%. Factors that contribute to cardiac patients’ lack of participation in rehabilitation programs are patient motivation, logistical difficulties in getting to the rehabilitation facilities, lack of psychosocial elements, and individualization of activities in the rehabilitation programs. Telerehabilitation has been proposed as a new way to address the challenge of engaging and motivating cardiac patients and their partners to participate in rehabilitation.

Objective

The aim of this study was to explore the experiences of cardiac patients and their partners of participating in the Teledialog Telerehabilitation Program (TTP). The Teledialog program consisted of a digital rehabilitation plan, transmission of health data from patient’s home to hospital and health care center, and an interactive Web portal with information and training videos.

Methods

This case study used a theoretical approach combining the “community of practice” approach and self-determination theory. A triangulation of data collection techniques was used, including documents, participant observation (72 hours), and qualitative interviews with cardiac patients and their partners enrolled in the telerehabilitation group. A total of 14 cardiac patients, 12 patient spouses/partners, and 1 son participated in the study. The participants were interviewed at enrollment in the telerehabilitation program and after 12 weeks of participation in the program. Interview data were analyzed using NVivo 11.0.

Results

Patients and their partners found the Web portal ActiveHeart.dk and the electronic rehabilitation (e-rehabilitation) plan to be helpful tools for health education, coordinating rehabilitation goals, creating an overview of the data, and ensuring continuity in the rehabilitation process. The patients felt that the TTP treated them as individuals, gave them a sense of autonomy, and provided enhanced relatedness to health care professionals and partners and a sense of competence as active participants in their own rehabilitation process. Some patients missed being part of a community of practice with other cardiac patients and did not use the Web forum. Patients’ partners found that the telerehabilitation program gave them a sense of security and helped them balance their involvement as a partner to the patient and not push the patient too hard.

Conclusions

Cardiac patients and their partners found telerehabilitation technologies a useful digital toolbox in the rehabilitation process. Telerehabilitation motivated the patients to integrate rehabilitation activities into their work schedule and everyday life and made them feel like unique individuals. Participating in the Teledialog Telerehabilitation Program might not be a suitable strategy for all cardiac patients. Being a patient’s partner in the telerehabilitation program was associated with a heightened sense of security, navigation between active involvement in the rehabilitation process, being an equal partner, and not pushing the patient too hard.

A case report on epicardial ultrasonography of coronary anastomoses using a stabilizing device without the use of ultrasound gel

BACKGROUND

Intraoperative epicardial ultrasonography of coronary artery bypass graft anastomoses is a procedure used for anatomical quality assessment of peripheral anastomoses during coronary artery bypass grafting. However, it may be difficult to keep the ultrasound transducer in steady contact with the anastomoses on the beating heart without causing any deformation. Furthermore, we are not aware of any sterile ultrasound gel approved for application into the pericardial space.

CASE PRESENTATION

We report a method using a stabilizing connecting device for an ultrasound transducer to be used for visualization of coronary anastomoses without application of ultrasound gel during on-pump coronary bypass surgery.

CONCLUSION

Use of a stabilizing device and coagulated blood from the patient as an alternative for ultrasound gel facilitates peroperative ultrasonography of coronary anastomoses. The procedure provides surgeons with non-deformed echocardiographic longitudinal and transverse images of all parts of the anastomoses.

TRIAL REGISTRATION

The patient participated in a still ongoing clinical feasibility study: Trial registration: ClinicalTrials.gov ID: NCT02919124 ; Registered September 29, 2016.

Conventional Rehabilitation Therapy Versus Telerehabilitation in Cardiac Patients: A Comparison of Motivation, Psychological Distress, and Quality of Life

Telerehabilitation (TR) has gained attention as a promising rehabilitation format. Our study examined how patients responded to TR and whether it provided adequate support for their lifestyle changes and self-care efforts when compared to conventional rehabilitation (CR). Cardiac patients (n = 136) were randomly assigned to a TR or CR group. The TR group was provided with relevant health care technology for a period of three months, and both groups filled in questionnaires on their motivation for lifestyle changes and self-care psychological distress, and quality of life at 0, 3, 6, and 12 months. Patients in both groups were found to be equally motivated for lifestyle changes and self-care (p < 0.05) and they experienced similar levels of psychological distress and quality of life. TR is comparable to conventional rehabilitation in motivating patients, preventing psychological distress and improving quality of life. Although we observed an initial increase in autonomous motivation in the telerehabilitation group, this positive difference in motivation does not last over time. As such, neither rehabilitation format seems able to ensure long-term motivation. Therefore, TR may serve as a viable replacement for conventional rehabilitation when considered relevant. Further research is needed to enhance long-term motivation, and maybe telerehabilitation can help to achieve this.

Carbon monoxide poisoning in Denmark with focus on mortality and factors contributing to mortality

Introduction

Carbon monoxide (CO) poisoning is frequent worldwide but knowledge regarding the epidemiology is insufficient. The aim of this study was to clarify the extent of this intoxication, its mortality and factors associated with mortality.

Materials and methods

National databases from Statistics Denmark were used to identify individuals who suffered from CO-poisoning during 1995–2015, as well as information regarding co-morbidities, mortality and manner of death.

Results

During the period from 1995 to 2015, 22,930 patients suffered from CO-poisoning in Denmark, and 21,138 of these patients (92%) were hospitalized. A total of 2,102 patients died within the first 30 days after poisoning (9.2%). Among these, 1,792 (85% of 2,102) were declared dead at the scene and 310 (15% of 2,102) died during hospitalization. Deaths due to CO-poisoning from smoke were intentional in 6.3% of cases, whereas deaths due to CO containing gases were intentional in 98.0% of cases. Among patients who survived >30 days, there was no significant difference in survival when comparing hyperbaric oxygen therapy (HBO) treatment with no HBO treatment after adjustment for age and co-morbidities such as drug abuse, psychiatric disease, stroke, alcohol abuse, arterial embolism, chronic obstructive pulmonary disease, cerebrovascular disease and atrial fibrillation. Several co-morbidities predicted poorer outcomes for patients who survived the initial 30 days.

Conclusions

Poisoning from smoke and/or CO is a frequent incident in Denmark accounting for numerous contacts with hospitals and deaths. Both intoxication and mortality are highly associated with co-morbidities interfering with cognitive and physical function. Treatment with HBO was not seen to have an effect on survival.

Percutaneous versus thoracoscopic ablation of symptomatic paroxysmal atrial fibrillation: a randomised controlled trial - the FAST II study

BACKGROUND

The most efficient first-time invasive treatment, for achieving sinus rhythm, in symptomatic paroxysmal atrial fibrillation has not been established. We aimed to compare percutaneous catheter and video-assisted thoracoscopic pulmonary vein radiofrequency ablation in patients referred for first-time invasive treatment due to symptomatic paroxysmal atrial fibrillation. The primary outcome of interest was the prevalence of atrial fibrillation with and without anti-arrhythmic drugs at 12 months.

METHODS

Ninety patients were planned to be randomised to either video-assisted thoracoscopic radiofrequency pulmonary vein ablation with concomitant left atrial appendage excision or percutaneous catheter pulmonary vein ablation. Episodes of atrial fibrillation were defined as more than 30 s of atrial fibrillation observed on Holter monitoring/telemetry or clinical episodes documented by ECG.

RESULTS

The study was terminated prematurely due to a lack of eligible patients. Only 21 patients were randomised and treated according to the study protocol. Thoracoscopic pulmonary vein ablation was performed in 10 patients, and 11 patients were treated with catheter ablation. The absence of atrial fibrillation without the use of anti-arrhythmic drugs throughout the follow-up was observed in 70% of patients following thoracoscopic pulmonary vein ablation and 18% after catheter ablation (p < 0.03).

CONCLUSION

Thoracoscopic pulmonary vein ablation may be superior to catheter ablation for first-time invasive treatment of symptomatic paroxysmal atrial fibrillation with regard to obtaining sinus rhythm off anti-arrhythmic drugs 12 months postoperative.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01336075 . Registered April 15th, 2011.

Inspiratory Muscle Training in High-Risk Patients Following Lung Resection May Prevent a Postoperative Decline in Physical Activity Level

Objectives. To describe postoperative self-reported physical activity (PA) level and assess the effects of 2 weeks of postoperative inspiratory muscle training (IMT) in patients at high risk for postoperative pulmonary complications following lung resection. Methods. This is a descriptive study reporting supplementary data from a randomized controlled trial that included 68 patients (mean age = 70 ± 8 years), randomized to an intervention group (IG; n = 34) or a control group (CG; n = 34). The IG underwent 2 weeks of postoperative IMT added to a standard postoperative physiotherapy given to both groups. The standard physiotherapy consisted of breathing exercises, coughing techniques, and early mobilization. We evaluated self-reported physical activity (Physical Activity Scale 2.1 questionnaire) and health status (EuroQol EQ-5D-5L questionnaire), assessed the day before surgery and 2 weeks postoperatively. Results. A significant percentage of the patients in the IG reported less sedentary activity 2 weeks postoperatively when compared with the CG (sedentary 6% vs 22%, low activity 56% vs 66%, moderate activity 38% vs 12%, respectively; P = .006). The mean difference in EQ-5D-5L between the IG and CG 2 weeks postoperatively was nonsignificant (P = .80). The overall preoperative EQ-5D-5L index score for the study population was comparable to a reference population. Conclusion. Postoperative IMT seems to prevent a decline in PA level 2 weeks postoperatively in high-risk patients undergoing lung resection. More research is needed to confirm these findings.

Cardiac patients' experiences with a telerehabilitation web portal: Implications for eHealth literacy

OBJECTIVE

The aims of this study are two-fold: 1) To explore how cardiac patients experience their use of a telerehabilitation tool for recuperation from surgery, and 2) To study how the patients' use of the interactive 'Active Heart' web portal affected their eHealth literacy skills.

METHODS

The 'Active Heart' telerehabilitation web portal offers patients and their relatives information and exercises for recovery from cardiac surgery. 109 cardiac patients were using the Active Heart web portal for a duration of three months.

RESULTS

49 patients completed questionnaires that were administered both before and after their use of the portal, resulting in a 45% response rate. Respondents had a mean age of 60.64 ± 10.75 years, and 82% of the respondents were males. The respondents had a positive impression of Active Heart, reporting that it was easy to access, user-friendly, and written in an understandable language. The patients' eHealth literacy skills increased during the trial period.

CONCLUSION

Use of a cardiac telerehabilitation web portal can be beneficial for patient education and can increase cardiac patients' eHealth literacy skills.

PRACTICE IMPLICATIONS

Online telerehabilitation portals may be used as a tool in patient education and cardiac rehabilitation.

Decrease in pulmonary function and oxygenation after lung resection

Respiratory deficits are common following curative intent lung cancer surgery and may reduce the patient's ability to be physically active. We evaluated the influence of surgery on pulmonary function, respiratory muscle strength and physical performance after lung resection.

Pulmonary function, respiratory muscle strength (maximal inspiratory/expiratory pressure) and 6-min walk test (6MWT) were assessed pre-operatively, 2 weeks post-operatively and 6 months post-operatively in 80 patients (age 68±9 years).

Video-assisted thoracoscopic surgery was performed in 58% of cases. Two weeks post-operatively, we found a significant decline in pulmonary function (forced vital capacity −0.6±0.6 L and forced expiratory volume in 1 s −0.43±0.4 L; both p<0.0001), 6MWT (−37.6±74.8 m; p<0.0001) and oxygenation (−2.9±4.7 units; p<0.001), while maximal inspiratory and maximal expiratory pressure were unaffected. At 6 months post-operatively, pulmonary function and oxygenation remained significantly decreased (p<0.001), whereas 6MWT was recovered.

We conclude that lung resection has a significant short- and long-term impact on pulmonary function and oxygenation, but not on respiratory muscle strength. Future research should focus on mechanisms negatively influencing post-operative pulmonary function other than impaired respiratory muscle strength.

Lung resection has a significant short- and long-term impact on pulmonary function and oxygenation, but not on respiratory muscle strengthhttp://ow.ly/WTqc30h6j4i

Quality assurance of the Western Denmark Heart Registry, a population-based healthcare register

INTRODUCTION

During the past decade, the mandatory population-based healthcare database, the Western Denmark Heart Registry (WDHR), has provided the data for several research projects. As in most clinical registries, the data quality has not been validated thoroughly. This study was undertaken to evaluate the quality of registrations in the WDHR.

METHODS

The audit supervised procedures from involved departments that were performed in 2013. An experienced research nurse completed data collection, and an experienced consultant evaluated the agreement between the WDHR and patient records. Indistinct data from patient records were determined after consulting a specialist from the department in question. Patient files were double-checked in case of disagreements between the involved systems.

RESULTS

The total proportion of errors in the referral date was 16.4% in surgery, 9.8% in percutaneous invasive procedures (PCI), 16.1% in coronary angiography (CAG) and 19.5% in computed tomography (CT)-CAG, while the errors in inhospital dates were slightly lower. In the cardiac surgery registries, the proportion of errors was 3.3% in the history and EuroSCORE module, 1.0% in the procedure module and 2.8% in the discharge module. For PCI procedures, the errors were 3.8% in the history module, 2.2% in the procedure module and 1.6% in the discharge module. CAG and CT-CAG had slightly more errors.

CONCLUSIONS

The quality control of the WDHR revealed that overall data errors were lower than 3% and for procedure-specific registrations including indications and complications, the error rate was below 1.5%. The WDHR is valid and may be used in contemporary epidemiological studies.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Accuracy of a step counter during treadmill and daily life walking by healthy adults and patients with cardiac disease

BACKGROUND

Step counters have been used to observe activity and support physical activity, but there is limited evidence on their accuracy.

OBJECTIVE

The purpose was to investigate the step accuracy of the Fitbit Zip (Zip) in healthy adults during treadmill walking and in patients with cardiac disease while hospitalised at home.

METHODS

Twenty healthy adults aged 39±13.79 (mean ±SD) wore four Zips while walking on a treadmill at different speeds (1.7-6.1 km/hour), and 24 patients with cardiac disease (age 67±10.03) wore a Zip for 24 hours during hospitalisation and for 4 weeks thereafter at home. A Shimmer3 device was used as a criterion standard.

RESULTS

At a treadmill speed of 3.6 km/hour, the relative error (±SD) for the Zips on the upper body was -0.02±0.67 on the right side and -0.09 (0.67) on the left side. For the Zips on the waist, this was 0.08±0.71 for the right side and -0.08 (0.47) on the left side. At a treadmill speed of 3.6 km/hour and higher, the average per cent of relative error was <3%. The 24-hour test for the hospitalised patients showed a relative error of -47.15±24.11 (interclass correlation coefficient (ICC): 0.60), and for the 24-hour test at home, the relative error was -27.51±28.78 (ICC: 0.87). Thus, none of the 24-hour tests had less than the expected 20% error. In time periods of evident walking during the 24 h test, the Zip had an average per cent relative error of <3% at 3.6 km/hour and higher speeds.

CONCLUSIONS

A speed of 3.6 km/hour or higher is required to expect acceptable accuracy in step measurement using a Zip, on a treadmill and in real life. Inaccuracies are directly related to slow speeds, which might be a problem for patients with cardiac disease who walk at a slow pace.

Storage time of intraoperative transfused allogeneic red blood cells is not associated with new-onset postoperative atrial fibrillation in cardiac surgery

BACKGROUND

Allogeneic red blood cell (RBC) transfusion has been associated with new-onset postoperative atrial fibrillation (POAF) following cardiac surgery. Prolonged storage time of RBC may increase the risk. The primary aim of the study was to evaluate whether the storage time of RBC is associated with development of POAF.

MATERIALS AND METHODS

Pre-, per- and postoperative data were retrieved from the Western Denmark Heart Registry and local blood banks regarding patients who underwent coronary artery bypass surgery, valve surgery or combined procedures in Aalborg or Aarhus University Hospital during 2010-2014. Multiple logistic regression was used to determine the risk of POAF according to transfusion of RBC on the day of surgery. Furthermore, we determined trend in storage time of RBC according to risk of POAF using restricted cubic splines. Patients with a history of preoperative atrial fibrillation, patients who received transfusions preoperative and patients who died at the day of surgery were among excluded patients.

RESULTS

A total of 2,978 patients with a mean age of 66.4 years were included and 609 patients (21%) received RBC transfusion on the day of surgery. POAF developed in 752 patients (25%) and transfused patients were at an increased risk compared with non-transfused patients (adjusted Odds Ratios for patients receiving RBC: 1.37; 95% CI: 1.11-1.69, P-value = 0.004). However, RBC transfusion was not necessarily the cause of POAF and may only be a marker for development of POAF. There was no significant association between storage time of RBC and POAF.

CONCLUSIONS

In contrast to intraoperative allogeneic RBC transfusion in general, increased storage time of RBC is not associated with development of POAF in cardiac surgery.

Regional muscle tissue saturation is an indicator of global inadequate circulation during cardiopulmonary bypass: a randomized porcine study using muscle, intestinal and brain tissue metabolomics

Background:

Muscle tissue saturation (StO2) measured with near-infrared spectroscopy has generally been considered a measurement of the tissue microcirculatory condition. However, we hypothesized that StO2 could be more regarded as a fast and reliable measure of global than of regional circulatory adequacy and tested this with muscle, intestinal and brain metabolomics at normal and two levels of low cardiopulmonary bypass blood flow rates in a porcine model.

Methods:

Twelve 80 kg pigs were connected to normothermic cardiopulmonary bypass with a blood flow of 60 mL/kg/min for one hour, reduced randomly to 47.5 mL/kg/min (Group I) or 35 mL/kg/min (Group II) for one hour followed by one hour of 60 mL/kg/min in both groups. Regional StO2 was measured continuously above the musculus gracilis (non-cannulated leg). Metabolomics were obtained by brain tissue oxygen monitoring system (Licox) measurements of the brain and microdialysis perfusate from the muscle, intestinal mucosa and brain. A non-parametric statistical method was used.

Results:

The systemic parameters showed profound systemic ischaemia during low CPB blood flow. StO2 did not change markedly in Group I, but in Group II, StO2 decreased immediately when blood flow was reduced and, furthermore, was not restored despite blood flow being normalized. Changes in the metabolomics from the muscle, colon and brain followed the changes in StO2.

Conclusion:

We found, in this experimental cardiopulmonary bypass model, that StO2 reacted rapidly when the systemic circulation became inadequate and, furthermore, reliably indicate insufficient global tissue perfusion even when the systemic circulation was restored after a period of systemic hypoperfusion.

Pedometer use and self-determined motivation for walking in a cardiac telerehabilitation program: a qualitative study

Background

Exercise-based cardiac rehabilitation reduces morbidity and mortality. Walking is a convenient activity suitable for people with cardiac disease. Pedometers count steps, measure walking activity and motivate people to increase physical activity. In this study, patients participating in cardiac telerehabilitation were provided with a pedometer to support motivation for physical activity with the purpose of exploring pedometer use and self-determined motivation for walking experienced by patients and health professionals during a cardiac telerehabilitation program.

Methods

A qualitative research design consisting of observations, individual interviews and patient documents made the basis for a content analysis. Data was analysed deductively using Self Determination Theory as a frame for analysis and discussion, focusing on the psychological needs of autonomy, competence and relatedness. Twelve cardiac patients, 11 health professionals, 6 physiotherapists and 5 registered nurses were included.

Results

The pedometer offered independence from standardised rehabilitation since the pedometer supported tailoring, individualised walking activity based on the patient’s choice. This led to an increased autonomy. The patients felt consciously aware of health benefits of walking, and the pedometer provided feedback on walking activity leading to an increased competence to achieve goals for steps. Finally, the pedometer supported relatedness with others. The health professionals’ surveillance of patients’ steps, made the patients feel observed, yet supported, furthermore, their next of kin appeared to be supportive as walking partners.

Conclusion

Cardiac patients’ motivation for walking was evident due to pedometer use. Even though not all aspects of motivation were autonomous and self determined, the patients felt motivated for walking. The visible steps and continuous monitoring of own walking activity made it possible for each individual patient to choose their desired kind of activity and perform ongoing adjustments of walking activity. The immediate feedback on step activity and the expectations of health benefits resulted in motivation for walking. Finally, pedometer supported walking made surveillance possible, giving the patients a feeling of being looked after and supported.

Trial registration

Current study is a part of The Teledi@log project.

Cardiac Patients' Walking Activity Determined by a Step Counter in Cardiac Telerehabilitation: Data From the Intervention Arm of a Randomized Controlled Trial

Background

Walking represents a large part of daily physical activity. It reduces both overall and cardiovascular diseases and mortality and is suitable for cardiac patients. A step counter measures walking activity and might be a motivational tool to increase and maintain physical activity. There is a lack of knowledge about both cardiac patients’ adherence to step counter use in a cardiac telerehabilitation program and how many steps cardiac patients walk up to 1 year after a cardiac event.

Objective

The purpose of this substudy was to explore cardiac patients’ walking activity. The walking activity was analyzed in relation to duration of pedometer use to determine correlations between walking activity, demographics, and medical and rehabilitation data.

Methods

A total of 64 patients from a randomized controlled telerehabilitation trial (Teledi@log) from Aalborg University Hospital and Hjoerring Hospital, Denmark, from December 2012 to March 2014 were included in this study. Inclusion criteria were patients hospitalized with acute coronary syndrome, heart failure, and coronary artery bypass grafting or valve surgery. In Teledi@log, the patients received telerehabilitation technology and selected one of three telerehabilitation settings: a call center, a community health care center, or a hospital. Monitoring of steps continued for 12 months and a step counter (Fitbit Zip) was used to monitor daily steps.

Results

Cardiac patients walked a mean 5899 (SD 3274) steps per day, increasing from mean 5191 (SD 3198) steps per day in the first week to mean 7890 (SD 2629) steps per day after 1 year. Adherence to step counter use lasted for a mean 160 (SD 100) days. The patients who walked significantly more were younger (P=.01) and continued to use the pedometer for a longer period (P=.04). Furthermore, less physically active patients weighed more. There were no significant differences in mean steps per day for patients in the three rehabilitation settings or in the disease groups.

Conclusions

This study indicates that cardiac telerehabilitation at a call center can support walking activity just as effectively as telerehabilitation at either a hospital or a health care center. In this study, the patients tended to walk fewer steps per day than cardiac patients in comparable studies, but our study may represent a more realistic picture of walking activity due to the continuation of step counter use. Qualitative studies on patients’ behavior and motivation regarding step counter use are needed to shed light on adherence to and motivation to use step counters.

Trial Registration

ClinicalTrails.gov NCT01752192; https://clinicaltrials.gov/ct2/show/NCT01752192 (Archived by WebCite at http://www.webcitation.org/6fgigfUyV)

30-day mortality after coronary artery bypass grafting and valve surgery has greatly improved over the last decade, but the 1-year mortality remains constant

Introduction:

European system for cardiac operative risk evaluation (EuroSCORE) is a valuable tool in control of the quality of cardiac surgery. However, the validity of the risk score for the individual patient may be questioned. The present study was carried out to investigate whether the continued fall in short-term mortality reflects an actual improvement in late mortality, and subsequently, to investigate EuroSCORE as predictor of 1-year mortality.

Methods:

A population-based cohort study of 25,602 patients from a 12-year period from three public university hospitals undergoing coronary artery bypass grafting (CABG) or valve surgery. Analysis was carried out based on EuroSCORE, age and co-morbidity factors (residual EuroSCORE).

Results:

During the period the average age increased from 65.1 ± 10.0 years to 68.9 ± 10.7 years (P < 0.001, one-way ANOVA), and the number of females increased from 26.0% to 28.2% (P = 0.0012, Chi-square test). The total EuroSCORE increased from 4.67 to 5.68 while the residual EuroSCORE decreased from 2.64 to 1.83. Thirty-day mortality decreased from 4.07% in 1999–2000 to 2.44% in 2011–2012 (P = 0.0056; Chi-square test), while 1-year mortality was unchanged (6.50% in 1999–2000 vs. 6.25% in 2011–2012 [P = 0.8086; Chi-square test]).

Discussion:

The study demonstrates that both co-morbidity and age has a great impact on 30-day mortality. However, with time the impact of co-morbidity seems less. Thus, age is more important than co-morbidity in late mortality. The various developments in short and long-term mortality are not readily explained.

Conclusion:

Although 30-day mortality of CABG and valve surgery patients has decreased during the 12-year period, the 1-year mortality remains the same.

No Effect of Rapamycin on Cardiac Adhesion Formation: A Drug-Loaded Bioresorbable Polylactone Patch in a Porcine Cardiac Surgical Model

Background: The fusing of the epicardium and sternum due to adhesion is a common problem during repeated cardiac surgery and carries with it an increased risk of bleeding. The use of barriers and patches has been tested to prevent the formation of adhesions, but the very presence of a patch can provoke adhesion formation. The objective of this study was, therefore, to investigate both biodegradable and bioresorbable polylactone patches [(polycaprolactone-poly(ethylene oxide)-polycaprolactone tri-block copolymer (PCE)]. The patches were also tested with a controlled release of rapamycin, which prevents cell migration and extracellular matrix deposition. The clinical effectiveness of rapamycin in pericardial patches has not previously been examined. Materials and Methods: Three groups of 6 female Danish Landrace pigs underwent sternotomy and abrasion of the epicardium, before being randomized to either group 1 - the control group (with no patch), group 2 - PCE patch implanted between the sternum and epicardium, or group 3 - PCE patch and slow-release 1.6-mg rapamycin. After a median time period of 26 days, the pigs were euthanized and their hearts removed en bloc with the sternum, for macroscopic, histological and pathological examination. Results: Upon macroscopic examination, a significantly lower degree of adhesion in group 2, as compared to group 1 (p < 0.05), was found. Histological analysis of the tissues showed significantly more fibrosis, inflammation and foreign body granulomas (p < 0.05) in both group 2 and group 3, when compared to group 1. Conclusion: A PCE patch following sternotomy in animal subjects reduces postoperative macroscopic adhesions without reducing microscopic fibrosis or inflammation. Loading the patch with rapamycin was found not to increase the antifibrotic effect.

Cost-Utility Analysis of a Cardiac Telerehabilitation Program: The Teledialog Project

Background:Cardiac rehabilitation can reduce mortality of patients with cardiovascular disease, but a frequently low participation rate in rehabilitation programs has been found globally. The objective of the Teledialog study was to assess the cost-utility (CU) of a cardiac telerehabilitation (CTR) program. The aim of the intervention was to increase the patients' participation in the CTR program. At discharge, an individualized 3-month rehabilitation plan was formulated for each patient. At home, the patients measured their own blood pressure, pulse, weight, and steps taken for 3 months.Materials and Methods:The analysis was carried out together with a randomized controlled trial with 151 patients during 2012–2014. Costs of the intervention were estimated with a health sector perspective following international guidelines for CU. Quality of life was assessed using the 36-Item Short Form Health Survey.Results:The rehabilitation activities were approximately the same in the two groups, but the number of contacts with the physiotherapist was higher among the intervention group. The mean total cost per patient was €1,700 higher in the intervention group. The quality-adjusted life-years (QALYs) gain was higher in the intervention group, but the difference was not statistically significant. The incremental CU ratio was more than €400,000 per QALY gained.Conclusions:Even though the rehabilitation activities increased, the program does not appear to be cost-effective. The intervention itself was not costly (less than €500), and increasing the number of patients may show reduced costs of the devices and make the CTR more cost-effective. Telerehabilitation can increase participation, but the intervention, in its current form, does not appear to be cost-effective.

Validation of post-operative atrial fibrillation in the Western Denmark Heart Registry

INTRODUCTION

Post-operative new-onset atrial fibrillation and flutter (POAF) is associated with increased morbidity and mortality following cardiac surgery. Registers and databases are important data sources for observational studies in this research area; hence, the aim was to assess the data validity of the POAF diagnosis in the Western Denmark Heart Registry (WDHR).

METHODS

We studied a 25% random sample (n = 1,381) from a cohort of 5,532 patients who underwent coronary artery bypass grafting, valve surgery or combinations between 1 January 2011 and 31 December 2013. Registrations of POAF diagnoses in the WDHR were compared with the actual clinical course as documented in the medical records. The positive predictive value for new-onset POAF in the WDHR was calculated.

RESULTS

A positive predictive value of 82.5% (95% confidence interval: 78.8-85.7) was found with a sensitivity and specificity of 75.2% and 90.9%, respectively.

CONCLUSIONS

A diagnosis of new-onset POAF in the WDHR is relatively valid and may be used for contemporary epidemiological studies. Improvements may optimise the registry's validity even further, emphasising the importance of continuous validation and maintenance of the registry.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Postoperative inspiratory muscle training in addition to breathing exercises and early mobilization improves oxygenation in high-risk patients after lung cancer surgery: a randomized controlled trial

OBJECTIVES

The aim was to investigate whether 2 weeks of inspiratory muscle training (IMT) could preserve respiratory muscle strength in high-risk patients referred for pulmonary resection on the suspicion of or confirmed lung cancer. Secondarily, we investigated the effect of the intervention on the incidence of postoperative pulmonary complications.

METHODS

The study was a single-centre, parallel-group, randomized trial with assessor blinding and intention-to-treat analysis. The intervention group (IG, n = 34) underwent 2 weeks of postoperative IMT twice daily with 2 × 30 breaths on a target intensity of 30% of maximal inspiratory pressure, in addition to standard postoperative physiotherapy. Standard physiotherapy in the control group (CG, n = 34) consisted of breathing exercises, coughing techniques and early mobilization. We measured respiratory muscle strength (maximal inspiratory/expiratory pressure, MIP/MEP), functional performance (6-min walk test), spirometry and peripheral oxygen saturation (SpO2), assessed the day before surgery and again 3-5 days and 2 weeks postoperatively. Postoperative pulmonary complications were evaluated 2 weeks after surgery.

RESULTS

The mean age was 70 ± 8 years and 57.5% were males. Thoracotomy was performed in 48.5% (n = 33) of cases. No effect of the intervention was found regarding MIP, MEP, lung volumes or functional performance at any time point. The overall incidence of pneumonia was 13% (n = 9), with no significant difference between groups [IG 6% (n = 2), CG 21% (n = 7), P = 0.14]. An improved SpO2 was found in the IG on the third and fourth postoperative days (Day 3: IG 93.8 ± 3.4 vs CG 91.9 ± 4.1%, P = 0.058; Day 4: IG 93.5 ± 3.5 vs CG 91 ± 3.9%, P = 0.02). We found no association between surgical procedure (thoracotomy versus thoracoscopy) and respiratory muscle strength, which was recovered in both groups 2 weeks after surgery.

CONCLUSIONS

Two weeks of additional postoperative IMT, compared with standard physiotherapy alone, did not preserve respiratory muscle strength but improved oxygenation in high-risk patients after lung cancer surgery. Respiratory muscle strength recovered in both groups 2 weeks after surgery.

CLINICAL TRIALSGOV ID

NCT01793155.

Estimation of utility values from visual analog scale measures of health in patients undergoing cardiac surgery

Introduction

In health economic evaluations, mapping can be used to estimate utility values from other health outcomes in order to calculate quality adjusted life-years. Currently, no methods exist to map visual analog scale (VAS) scores to utility values. This study aimed to develop and propose a statistical algorithm for mapping five dimensions of health, measured on VASs, to utility scores in patients suffering from cardiovascular disease.

Methods

Patients undergoing coronary artery bypass grafting at Aalborg University Hospital in Denmark were asked to score their health using the five VAS items (mobility, self-care, ability to perform usual activities, pain, and presence of anxiety or depression) and the EuroQol 5 Dimensions questionnaire. Regression analysis was used to estimate four mapping models from patients’ age, sex, and the self-reported VAS scores. Prediction errors were compared between mapping models and on subsets of the observed utility scores. Agreement between predicted and observed values was assessed using Bland–Altman plots.

Results

Random effects generalized least squares (GLS) regression yielded the best results when quadratic terms of VAS scores were included. Mapping models fitted using the Tobit model and censored least absolute deviation regression did not appear superior to GLS regression. The mapping models were able to explain approximately 63%–65% of the variation in the observed utility scores. The mean absolute error of predictions increased as the observed utility values decreased.

Conclusion

We concluded that it was possible to predict utility scores from VAS scores of the five dimensions of health used in the EuroQol questionnaires. However, the use of the mapping model may be inappropriate in more severe conditions.

[Surgical thoracoscopic treatment of atrial fibrillation as an alternative to percutaneous radio frequency ablation]

The prevalence of atrial fibrillation in the general population is 1-2% and ablation procedures have been introduced among some symptomatic patients on order to obtain sinus rythm. A surgical thoracoscopic procedure may be offered to patients in whom percutaneous procedures were unsuccessful. This paper describes the procedure and initial results from 21 patients operated at Aalborg University Hospital, Denmark. Six months post-operatively 15 of 20 patients had obtained sinus rythm. Systematic follow-up is missing in local hospitals, indicating the need for systematic reporting to a clinical database.

[Possible decrease in the prevalence of nosocomial infections after the accreditation process in the region of Northern Jutland, Denmark]

All hospitals in the region of Northern Jutland, Denmark, were accredited in 2011 according to standards defined by the Danish Healthcare Quality Programme. A retrospective review was performed analysing the prevalence of nosocomial infections before and during the accreditation process. The accreditation process was associated with a decreased prevalence of selected nosocomial infections compared with results from a period immediate prior to the process. However, the findings were not statistically significant when the results were adjusted for patient-time in the hospitals.