Erector spinae plane blocks for opioid-sparing multimodal pain management after pediatric cardiac surgery

OBJECTIVE

Peripheral regional anesthesia is proposed to enhance recovery. We sought to evaluate the efficacy of bilateral continuous erector spinae plane blocks (B-ESpB) for postoperative analgesia and the impact on recovery in children undergoing cardiac surgery.

METHODS

Patients aged 2 through 17 years undergoing cardiac surgery in the enhanced recovery after cardiac surgery program were prospectively enrolled to receive B-ESpB at the end of the procedure, with continuous infusions via catheters postoperatively. Participants wore an activity monitor until discharge. B-ESpB patients were retrospectively matched with control patients in the enhanced recovery after cardiac surgery program. Outcomes of the matched clusters were compared using exact conditional logistic regression and generalized linear modeling.

RESULTS

Forty patients receiving B-ESpB were matched to 78 controls. There were no major complications from the B-ESpB or infusions, and operating room time was longer by a median of 31 minutes. While blocks were infusing, patients with B-ESpB received fewer opioids in oral morphine equivalents than controls at 24 hours (0.60 ± 0.06 vs 0.78 ± 0.04 mg/kg; P = .02) and 48 hours (1.13 ± 0.08 vs 1.35 ± 0.06 mg/kg; P = .04), respectively. Both groups had low median pain scores per 12-hour period. There was no difference in early mobilization, length of stay, or complications.

CONCLUSIONS

B-ESpBs are safe in children undergoing cardiac surgery. When performed as part of a multimodal pain strategy in an enhanced recovery after cardiac surgery program, pediatric patients with B-ESpB experience good pain control and require fewer opioids in the first 48 hours.

The respiratory syncytial virus prefusion F protein vaccine attenuates the severity of respiratory syncytial virus-associated disease in breakthrough infections in adults ≥60 years of age

Background

Respiratory syncytial virus (RSV) is a contagious pathogen causing acute respiratory infections (ARIs). Symptoms range from mild upper respiratory tract infections to potentially life-threatening lower respiratory tract disease (LRTD). In adults ≥60 years old, vaccine efficacy of a candidate vaccine for older adults (RSVPreF3 OA) was 71.7% against RSV-ARI and 82.6% against RSV-LRTD (AReSVi-006/NCT04886596). We present the patient-reported outcomes (PROs) from the same trial at the end of the first RSV season in the northern hemisphere (April 2022).

Methods

In this phase 3 trial, adults aged ≥60 years were randomized (1:1) to receive one dose of RSVPreF3 OA vaccine or placebo. PROs were assessed using InFLUenza Patient-Reported Outcome (FLU-PRO), Short Form-12 (SF-12), and EuroQol-5 Dimension (EQ-5D) questionnaires. Peak FLU-PRO Chest/Respiratory scores during the first 7 days from ARI episode onset were compared using a Wilcoxon test. Least squares mean (LSMean) of SF-12 physical functioning (PF) and EQ-5D health utility scores were estimated using mixed effects models.

Results

In the RSVPreF3 OA group (N = 12,466), 27 first RSV-ARI episodes were observed versus 95 in the Placebo group (N = 12,494). Median peak FLU-PRO Chest/Respiratory scores were lower in RSVPreF3 OA (1.07) versus Placebo group (1.86); p = 0.0258. LSMean group differences for the PF and EQ-5D health utility score were 7.00 (95% confidence interval [CI]: -9.86, 23.85; p = 0.4125) and 0.0786 (95% CI: -0.0340, 0.1913; p = 0.1695).

Conclusions

The RSVPreF3 OA vaccine, in addition to preventing infection, attenuated the severity of RSV-associated symptoms in breakthrough infections, with trends of reduced impact on PF and health utility.

Gaussian Process-based prediction of memory performance and biomarker status in ageing and Alzheimer's disease-A systematic model evaluation

Neuroimaging markers based on Magnetic Resonance Imaging (MRI) combined with various other measures (such as genetic covariates, biomarkers, vascular risk factors, neuropsychological tests etc.) might provide useful predictions of clinical outcomes during the progression towards Alzheimer's disease (AD). The use of multiple features in predictive frameworks for clinical outcomes has become increasingly prevalent in AD research. However, many studies do not focus on systematically and accurately evaluating combinations of multiple input features. Hence, the aim of the present work is to explore and assess optimal combinations of various features for MR-based prediction of (1) cognitive status and (2) biomarker positivity with a multi-kernel learning Gaussian process framework. The explored features and parameters included (A) combinations of brain tissues, modulation, smoothing, and image resolution; (B) incorporating demographics & clinical covariates; (C) the impact of the size of the training data set; (D) the influence of dimensionality reduction and the choice of kernel types. The approach was tested in a large German cohort including 959 subjects from the multicentric longitudinal study of cognitive impairment and dementia (DELCODE). Our evaluation suggests the best prediction of memory performance was obtained for a combination of neuroimaging markers, demographics, genetic information (ApoE4) and CSF biomarkers explaining 57% of outcome variance in out-of-sample predictions. The highest performance for Aβ42/40 status classification was achieved for a combination of demographics, ApoE4, and a memory score while usage of structural MRI further improved the classification of individual patient's pTau status.

Measurements of neutrino oscillation parameters from the T2K experiment using 3.6×1021 protons on target

The T2K experiment presents new measurements of neutrino oscillation parameters using 19.7 ( 16.3 ) × 10 20 protons on target (POT) in (anti-)neutrino mode at the far detector (FD). Compared to the previous analysis, an additional 4.7 × 10 20 POT neutrino data was collected at the FD. Significant improvements were made to the analysis methodology, with the near-detector analysis introducing new selections and using more than double the data. Additionally, this is the first T2K oscillation analysis to use NA61/SHINE data on a replica of the T2K target to tune the neutrino flux model, and the neutrino interaction model was improved to include new nuclear effects and calculations. Frequentist and Bayesian analyses are presented, including results on sin 2 θ 13 and the impact of priors on the δ CP measurement. Both analyses prefer the normal mass ordering and upper octant of sin 2 θ 23 with a nearly maximally CP-violating phase. Assuming the normal ordering and using the constraint on sin 2 θ 13 from reactors, sin 2 θ 23 = 0 . 561 - 0.032 + 0.021 using Feldman-Cousins corrected intervals, and Δ m 32 2 = 2 . 494 - 0.058 + 0.041 × 10 - 3 eV 2 using constant Δ χ 2 intervals. The CP-violating phase is constrained to δ CP = - 1 . 97 - 0.70 + 0.97 using Feldman-Cousins corrected intervals, and δ CP = 0 , π is excluded at more than 90% confidence level. A Jarlskog invariant of zero is excluded at more than 2 σ credible level using a flat prior in δ CP , and just below 2 σ using a flat prior in sin δ CP . When the external constraint on sin 2 θ 13 is removed, sin 2 θ 13 = 28 . 0 - 6.5 + 2.8 × 10 - 3 , in agreement with measurements from reactor experiments. These results are consistent with previous T2K analyses.

Mesoscale habitat use by St. Lawrence estuary beluga over the annual cycle from an acoustic recording network

The spatial-temporal distribution pattern of St. Lawrence Estuary (SLE) beluga is examined with a passive acoustic monitoring network of 13 stations from June 2018 to October 2021. A beluga calling index, correlated with beluga density, is used as a proxy for habitat use by the population at weekly, monthly, and yearly scales. The seasonal pattern along SLE upstream-downstream axis was repeated annually. In summer, beluga habitat was confined to a 150 km segment of the SLE, with higher occurrences in its ∼20 km central portion, including the head of the Laurentian Channel and Saguenay Fjord mouth. During fall, the distribution gradually shifted to the downstream portion of the SLE and into the Northwestern Gulf, leaving low to no occurrences upstream in winter, until the spring return, characterized by the highest upstream occurrences. Occurrences off Ste. Marguerite Bay, 25 km upstream in Saguenay Fjord, were essentially from June to October. This multi-year continuous habitat use pattern provides a baseline for year-round SLE beluga distribution dynamics for assessing and mitigating anthropogenic threats to this endangered population, such as shipping noise. It also provides insights for optimizing the assessments of population size from aerial line transect surveys.

ECMO During COVID-19: A Society of Thoracic Surgeons/Extracorporeal Life Support Organization Survey

BACKGROUND

The Society of Thoracic Surgeons Workforce on Critical Care and the Extracorporeal Life Support Organization sought to identify how the coronavirus disease 2019 (COVID-19) pandemic has changed the practice of venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) programs across North America.

METHODS

A 26-question survey covering 6 categories (ECMO initiation, cannulation, management, anticoagulation, triage/protocols, and credentialing) was emailed to 276 North American Extracorporeal Life Support Organization centers. ECMO practices before and during the COVID-19 pandemic were compared.

RESULTS

Responses were received from 93 (34%) programs. The percentage of high-volume (>20 cases per year) VV ECMO programs increased during the pandemic from 29% to 41% (P < .001), as did institutions requiring multiple clinicians for determining initiation of ECMO (VV ECMO, 25% to 43% [P = .001]; VA ECMO, 20% to 32% [P = .012]). During the pandemic, more institutions developed their own protocols for resource allocation (23% before to 51%; P < .001), and more programs created sharing arrangements to triage patients and equipment with other centers (31% to 57%; P < .001). Direct thrombin inhibitor use increased for both VA ECMO (13% to 18%; P = .025) and VV ECMO (12% to 24%; P = .005). Although cardiothoracic surgeons remained the primary cannulating proceduralists, VV ECMO cannulations performed by pulmonary and critical care physicians increased (13% to 17%; P = .046).

CONCLUSIONS

The Society of Thoracic Surgeons/Extracorporeal Life Support Organization collaborative survey indicated that the pandemic has affected ECMO practice. Further research on these ECMO strategies and lessons learned during the COVID-19 pandemic may be useful in future global situations.

[The proper use of oral nutritional supplements in a French Ehpad]

Undernutrition in residents of residential care facilities for the dependent elderly can be managed by oral nutritional supplements (ONS). The objective of this study is to evaluate their proper use. A total of 41.9% of residents on NOCs were malnourished on the day of the audit, compared with 71.5% before the introduction of NOCs. NOCs were administered according to the dietician's prescription, which differed from the doctor's prescription in more than half of the cases. NOCs were fully consumed by 79.2% of residents.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Palmar striated xanthomas in clinical practice

Introduction

The aim of this study was to assess the occurrence of palmar striated xanthomas (PSX) in a wide spectrum of lipid disorders ranging from very severe hypercholesterolemia (homozygous familial hypercholesterolemia) to very severe hypertriglyceridemia (chylomicronemia).

Methods

This study involved 3,382 dyslipidemic Caucasian adult patients (1,856 men and 1,526 women) seen at the Chicoutimi Hospital Lipid Clinic (Quebec, Canada), covering a wide range of lipid disorders, from severe hypertriglyceridemia to severe hypercholesterolemia. Categorical variables were compared using the Pearson χ2 statistic, whereas univariate analysis of variance (ANOVA) or nonparametric Kruskal-Wallis were used for continuous variables.

Results

A total of 5.1% (173/3382) of the studied patients presented PSX, a majority of them (67.1%) being women. PSX were observed in 18.8% of patients with dysbetalipoproteinemia and also among 14.1% of hypertriglyceridemic patients with partial lipoprotein lipase deficiency, 3.7% of patients with chylomicronemia and in all of those with homozygous familial hypercholesterolemia. Overall, 10.7% of patients with PSX did not meet dysbetalipoproteinemia diagnosis criteria.

Conclusion

According to our study, the PSX prevalence estimate among patients without dysbetalipoproteinemia would be around 10% and they could be observed in a wide spectrum of lipid disorders associated with recurrent or sustained remnant lipoprotein accumulation.

2021: Perioperative and Critical Care Year in Review for the Cardiothoracic Surgery Team

For yet another year, our lives have been dominated by a pandemic. This year in review, we feature an expert panel opinion regarding extracorporeal support in the context of COVID-19, challenging previously held standards. We also feature survey results assessing the impact of the pandemic on cardiac surgical volume. Furthermore, we focus on a single center experience that evaluated the use of pulmonary artery catheters and the comparison of transfusion strategies in the Restrictive and Liberal Transfusion Strategies in Patients With Acute Myocardial Infarction (REALITY) trial. Additionally, we address the impact of acute kidney injury on cardiac surgery and highlight the controversy regarding the choice of fluid resuscitation. We close with an evaluation of dysphagia in cardiac surgery and the impact of prehabilitation to optimize surgical outcomes.

Race and Outcomes in Patients with Congenital Cardiac Disease in an Enhanced Recovery Program

OBJECTIVES

Disparities in perioperative outcomes exist. In addition to patient and socioeconomic factors, racial disparities in outcome measures may be related to issues at the provider and institutional levels. Recognizing a potential role of standardized care in mitigating provider bias, this study aims to compare the perioperative sedation and pain management and consequent outcomes in Enhanced Recovery After Surgery (ERAS) cardiac patients of different races undergoing congenital heart surgery at a single quaternary children's hospital.

DESIGN

A retrospective study.

SETTING

A single quaternary pediatric hospital.

PARTICIPANTS

Patients, infants to adults, undergoing elective congenital cardiac surgery and enrolled in the ERAS protocol from October 2018 to December 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the patients, 872 were reviewed and 606 with race information were analyzed. There was no significant difference in intraoperative and postoperative oral morphine equivalent, perioperative sedatives, and regional blockade in Asian or African American patients when compared to White patients. Postoperative pain scores and outcomes among African American and Asian races were also not statistically different when compared to White patients.

CONCLUSIONS

Racial disparity in perioperative management and outcomes in patients with standardized ERAS protocols does not exist at the authors' institution. Future comparative studies of ERAS noncardiac patients may provide additional information on the role of standardization in reducing implicit bias.

Modified AngioVac System use With Extracorporeal Membrane Oxygenation in a Child With Fontan Thrombosis

The AngioVac System (AVS) extracts venous and pulmonary artery (PA) thrombi. We report modified use of the second-generation AVS with concurrent venoarterial extracorporeal membrane oxygenation (VA-ECMO) in a 10-year-old, 23 kg patient with failing Fontan circulation due to acute-on-chronic Fontan and PA thrombosis. Emergent femoral VA-ECMO was initiated for profound hypoxemia during cardiac catheterization. Fluoroscopy-guided thrombo-embolectomy was performed with AVS components. A two-venous limb inflow cannulation strategy was used; the AngioVac cannula (AVC) was positioned in the central PA and joined to the existing ECMO venous-limb. Thrombus extraction proceeded by clamping the ECMO venous-limb with the existing VA-ECMO centrifugal pump generating negative pressure to the AVC. Extracorporeal membrane oxygenation arterial-limb access was used for blood return. Settings to avoid cavitation were a maximal negative pressure of 100 mmHg using <3500 RPMs. To access the branch PAs, the AVC was replaced by a custom-modified 17 Fr arterial ECMO cannula. Clot retrieval was sufficient for improved clinical status enabling ECMO discontinuation within 24-hours, and discharge home 26-days later. This is the first description of successful subtotal thrombo-embolectomy with AVS components in a child with Fontan physiology concurrently supported on VA-ECMO, using one centrifugal pump. Although feasible, circuit modifications and close monitoring are required to avoid complications.

Enhancing Recovery in Congenital Cardiac Surgery

BACKGROUND

The benefits of a comprehensive enhanced recovery after surgery (ERAS®) program for the congenital heart disease population are largely unknown. We evaluated adherence and outcomes following a recently implemented enhanced recovery program (ERP) in congenital cardiac surgery.

METHODS

Patients undergoing elective surgery for simple and moderately complex congenital cardiac surgery followed institutional ERP guidelines since 10/2018. Adherence to guidelines over a 12-month period (P2) was compared to implementation data (P1:5 months). The association of outcomes with continuous time was estimated using linear regression.

RESULTS

Among 559 patients (representing 40% of the cardiac surgical volume) following the ERP over a period of 17 months, no differences in patient characteristics were observed between periods, except higher incidence of prior operations in P2. Adherence to many aspects of guidelines improved from P1 to P2. Notably, operating room extubation: 27% in P2 vs.16% in P1, p=0.006; decrease in median ventilation time: 6.0-hrs (IQR 0-9.2) in P2 vs. 7.6-hrs (IQR 3.8-12.3) in P1, p=0.002. In addition, there was a reduction in opioids, reported as oral morphine equivalents (OME), most significant for intraoperative OME: 5.00 mg/kg (3.11-7.60) in P2 vs. 6.05 mg/kg (3.77-9.78) in P1, p=0.001. There was no difference in overall intensive care unit (ICU) and postoperative length of stay except in lower risk surgeries. Surgical outcomes were similar in the two periods.

CONCLUSIONS

An enhanced recovery program reduced the use of opioids, led to more OR extubation and reduced mechanical ventilation duration in patients undergoing congenital cardiac surgery.

Return to work and quality of life after trauma: A systematic review

Background

Globally, one-tenth of the disability-adjusted life-years (DALYs) are due to injuries. Injuries can reduce employment opportunities and significantly affect the quality of life (QOL). Most research on these outcomes tend to focus on specific mechanisms of injury like road traffic crashes or falls, or body regions affected such as brain or limbs. But rarely do patients come with just body region injured nor does the healthcare system only treat one specific mechanism of injury. Therefore, we aimed to assess and provide a systematic overview of current knowledge about return to work (RTW) and QOL among adult injured patients up to 1-year after discharge.

Methods

We conducted a systematic review of the literature published since 2010 on RTW and QoL among injured patients. Three databases (MEDLINE, EMBASE, the Cochrane Library) were used. Meta-analysis was performed based on outcome, measurement tool, and the effect measure. Methodological quality of the studies were evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal Tool Checklist.

Results

41 articles were included in this review. More than one-third (36%) of patients had not yet returned to back to work even after 1-year. Those who did get back to work took an average time of more than 3 months. The QOL scores of the injured patients had not reached the general population or pre-injury levels even up to a year post-discharge. Women and the elderly tended have poorer outcomes and were under-represented in the studies. Over 75% of the included studies were from high-income countries (HICs) and had higher methodological quality. There were no studies from low-income countries (LICs).

Conclusions

RTW and QOL continue to remain a challenge even up to year since discharge after an injury, more so among women and the elderly. Health policy and practice should address this burden. Future studies should focus on building of high-quality evidence from LMICs on RTW and QOL among injury survivors.

Key messages

Return to work and quality of life were significantly low even after 1-year in trauma patients, especially among elderly and females. Larger representation of elderly, females, and participants from low- and middle-income setting in future long-term research on trauma patients.

Extracorporeal cardiopulmonary resuscitation (ECPR) survival: A quaternary center analysis

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue strategy for nonresponders to conventional CPR (CCPR) in cardiac arrest. Definitive guidelines for ECPR deployment do not exist. Prior studies suggest that arrest rhythm and cardiac origin of arrest may be variables used to assess candidacy for ECPR.

AIM

To describe a single-center experience with ECPR and to assess associations between survival and physician-adjudicated origin of arrest and arrest rhythm.

METHODS

A retrospective review of all patients who underwent ECPR at a quaternary care center over a 7-year period was performed. Demographic and clinical characteristics were extracted from the medical record and used to adjudicate the origin of cardiac arrest, etiology, rhythm, survival, and outcomes. Univariate analysis was performed to determine the association of patient and arrest characteristics with survival.

RESULTS

Between 2010 and 2017, 47 cardiac arrest patients were initiated on extracorporeal membrane oxygenation (ECMO) at the time of active CPR. ECPR patient survival to hospital discharge was 25.5% (n = 12). Twenty-six patients died on ECMO (55.3%) while nine patients (19.1%) survived decannulation but died before discharge. Neither physician-adjudicated arrest rhythm nor underlying origin were significantly associated with survival to discharge, either alone or in combination. Younger age was significantly associated with survival. Nearly all survivors experienced myocardial recovery and left the hospital with a good neurological status.

CONCLUSIONS

Arrest rhythm and etiology may be insufficient predictors of survival in ECPR utilization. Further multiinstitutional studies are needed to determine evidenced-based criteria for ECPR deployment.

Identifying Markers of Cardiovascular Event-Free Survival in Familial Hypercholesterolemia

Familial hypercholesterolemia (FH) is an autosomal dominant trait characterized by elevated low-density lipoprotein-cholesterol (LDL-C) concentrations appearing at birth and is associated with increased risk of premature atherosclerotic cardiovascular disease (CVD). However, in some cases, FH subjects over 70 years of age have surprisingly never experienced any CVD symptoms throughout their entire lives. The objective of this study consists of identifying biological and environmental markers acting as cardioprotective factors and associated with unexpected survival in FH. Upon age and reported cardiovascular events (CVE) stratification, we identified a total of 458 French–Canadian FH subjects with premature reported CVE, and 1297 young adults as well as 24 elderly subjects (≥70 years) who have never reported CVE requiring hospitalization. Logistic regression models were used to depict cardioprotective markers among FH survivors (≥70 years). Regression analyses of the FH cohort showed that female sex (odds ratio (OR) = 12.92 (4.23–39.46); p < 0.0001), high levels of high-density lipoprotein (HDL)-C (OR = 6.76 (2.43–18.79); p = 0.0002) and elevated concentrations of adiponectin (OR = 71.40 (5.20–980.47); p = 0.001) were significant contributory factors in reducing FH-related CVD risk. Notably, female (OR = 11.45 (1.25–105.98); p = 0.031) and high HDL-C (OR = 9.78 (1.75–54.67); p = 0.009) were shown to be significant covariates associated with survival in FH. Non-smoking (OR = 11.73 (4.36–31.56); p < 0.0001) was also identified as an environmental factor associated with CVE-free survival. Based on this configured model of premature CVE occurrence, these results demonstrated that, beyond LDL-C levels, female sex, high HDL-C, elevated adiponectin and non-smoking are important markers that contribute to a reduced risk of CVD and CVE-free survival in FH.

Bilateral Erector Spinae Blocks Decrease Perioperative Opioid Use After Pediatric Cardiac Surgery

OBJECTIVE

The present study examined the feasibility and efficacy of continuous bilateral erector spinae blocks for post-sternotomy pain in pediatric cardiac surgery.

DESIGN

Prospective cohort study; patients were retrospectively matched 1:2 to control patients. Conditional logistic regression was used to compare dichotomous outcomes, and generalized linear models were used for continuous measures, both accounting for clusters.

SETTING

Quaternary children's hospital, university setting.

PARTICIPANTS

The study comprised 10 children ages five-to-17 years undergoing elective cardiac surgery requiring cardiopulmonary bypass.

INTERVENTIONS

Ultrasound-guided bilateral erector spinae blocks at the conclusion of the cardiac surgical procedure, with postoperative infusion of ropivacaine until chest tube removal. Postoperative management otherwise followed standardized guidelines.

MEASUREMENTS AND MAIN RESULTS

Patient characteristics were similar in the two groups. The median time to completion of the bilateral blocks was 16.0 minutes (interquartile range [IQR] 14.8-19.3), and no major adverse events were identified. Pain scores were low in both groups. Postoperative opioid use at 48 hours, rendered as oral morphine equivalents, was significantly reduced in the patients receiving the blocks. Cluster-adjusted squared-root-transformed means ± standard error were 0.89 ± 0.06 mg/kg for patients receiving the blocks versus 1.05 ± 0.06 mg/kg for control patients (p = 0.04; raw medians 0.81 [IQR 0.41-1.04] v 1.10 [IQR 0.78-1.35] mg/kg, respectively). There were no differences in recovery metrics, length of stay, or complications.

CONCLUSIONS

Bilateral erector spinae blocks were associated with a reduction in opioid use in the first 48 hours after pediatric cardiac surgery compared with a matched cohort from the enhanced recovery program. Larger studies are needed to determine whether this can result in an improvement in recovery and patient satisfaction.

Association of common gene-smoking interactions with elevated plasma apolipoprotein B concentration

Background

Increased apolipoprotein (apo) B level (hyperapoB) is a strong predictor of cardiovascular disease (CVD), even in patients who achieve recommended LDL-Cholesterol (LDL-C) goals. ApoB level, an important correlate of metabolic syndrome (MetS), is influenced by several gene-environment interactions. Some of them are rare and can explain a large proportion of apoB variance, whereas others more common have variable effects. The aim of this study was to evaluate the association of interaction between smoking and common hyperapoB gene variants (PPARα-L162V, lipoprotein lipase loss-of function mutation, apo e4 allele or apo E2/2 genotype) with plasma apoB concentrations, according to the expression of MetS.

Methods

This study was performed among 1798 subjects. Smoking was defined as non/mild smokers vs. moderate-to-heavy smokers. ApoB levels were determined using nephelometry. Logistic regression models were used to document interactions between smoking habits and the presence of hyperapoB gene variants on the relative odds to exhibit increased plasma apoB concentrations.

Results

Around 29% of individuals with a low-risk lipid profile without MetS component had hyperapoB. Smoking and the presence of hyperapoB gene variants tended to be associated with higher plasma apoB levels even in presence of low-LDL-C. There was a significant interaction (P = 0.04) between the presence of ≥1 gene variants and smoking on the risk to exhibit hyperapoB among subjects with low risk profile in primary prevention.

Conclusions

Combination of life habits assessment and some common genes variants may detect a significant proportion of patients with increased apoB levels, and therefore a higher risk of CVD, who could have been initially perceived as low-risk.

Two-sex life table and feeding dynamics of Spilosoma obliqua Walker (Lepidoptera: Arctiidae) on three green gram cultivars

The effect of three green gram cultivars (PDM 54, PUSA BAISAKHI and SAMRAT) on the biology of Spilosoma obliqua Walker (Lepidoptera: Arctiidae) was studied using age-stage, two-sex life table. We also studied food utilization efficiency measures of larvae on green gram cultivars. The nutritional and antinutritional factors of leaves of green gram cultivars were determined. The preadult development time of S. obliqua was shortest on PDM 54 (35.54 days) and longest on SAMRAT (39.29 days). The fecundity was highest on PDM 54 (318.32) and lowest on SAMRAT (250.20). The net reproductive rate (R0) ranged from 37.53 on SAMRAT to 79.58 on PDM 54. The intrinsic rate of increase (r) was higher on PDM 54 (0.1148 day-1) and PUSA BAISAKHI (0.1018 day-1) than SAMRAT (0.0875 day-1). The finite rate of increase (λ) was lowest on SAMRAT (1.0915 day-1). Mean generation time (T) was shortest on PDM 54 (38.12 days) and longest on SAMRAT (41.42 days). Population projection revealed that the population growth was slowest on SAMRAT. The growth rate of sixth instar larvae was highest on PDM 54 and lowest on SAMRAT. The lower level of nutritional factors such as total carbohydrates, proteins, lipids, amino acids and nitrogen content, and a higher level of antinutritional factors such as total phenols, flavonols and tannins influenced higher development time and lower fecundity of S. obliqua on SAMRAT than other cultivars. These findings suggested that SAMRAT is a less suitable cultivar to S. obliqua than other cultivars, and this cultivar can be promoted for cultivation.

Performance of a deep neural network at detecting North Atlantic right whale upcalls

Passive acoustics provides a powerful tool for monitoring the endangered North Atlantic right whale (Eubalaena glacialis), but robust detection algorithms are needed to handle diverse and variable acoustic conditions and differences in recording techniques and equipment. This paper investigates the potential of deep neural networks (DNNs) for addressing this need. ResNet, an architecture commonly used for image recognition, was trained to recognize the time-frequency representation of the characteristic North Atlantic right whale upcall. The network was trained on several thousand examples recorded at various locations in the Gulf of St. Lawrence in 2018 and 2019, using different equipment and deployment techniques. Used as a detection algorithm on fifty 30-min recordings from the years 2015-2017 containing over one thousand upcalls, the network achieved recalls up to 80% while maintaining a precision of 90%. Importantly, the performance of the network improved as more variance was introduced into the training dataset, whereas the opposite trend was observed using a conventional linear discriminant analysis approach. This study demonstrates that DNNs can be trained to identify North Atlantic right whale upcalls under diverse and variable conditions with a performance that compares favorably to that of existing algorithms.

Decadal passive acoustics time series of St. Lawrence estuary beluga

Passive acoustics is used to monitor the threatened St. Lawrence estuary beluga between 2007 and 2017 from a site downstream of the beluga summer habitat. Acoustic metrics of presence and occurrence based on beluga acoustic band activity (BABA) are extracted by a dedicated algorithm adapted for the shipping noise from the St. Lawrence Seaway. A formal optimization process is used to set the algorithm parameters. Results evidence a year-round occurrence of belugas in the region, seasonal and diel patterns, and significant inter-annual variations. This study shows how passive acoustics methodology can be applied to monitor a loquacious species over multi-year periods in a shipping-noise-dominated environment, in order to understand its use of the habitat over the continuum of ecologically significant time scales.

Is quality of life after mastectomy comparable to that after breast conservation surgery? A 5-year follow up study from Mumbai, India

PURPOSE

Breast cancer is the commonest cancer in women worldwide. Surgery is a central part of the treatment. Modified radical mastectomy (MRM) is often replaced by breast conserving therapy (BCT) in high-income countries. MRM is still the standard choice, in low- and middle-income countries (LMICs) as radiotherapy, a mandatory component of BCT is not widely available. It is important to understand whether quality of life (QOL) after MRM is comparable to that after BCT. This has not been studied well in LMICs. We present, 5-year follow-up of QOL scores in breast cancer patients from India.

METHODS

We interviewed women undergoing breast cancer surgery preoperatively, at 6 months after surgery, and at 1 year and 5 years, postoperatively. QOL scores were evaluated using FACT B questionnaire. Average QOL scores of women undergoing BCT were compared with those undergoing MRM. Total scores, domain scores and trends of scores over time were analyzed.

RESULTS

We interviewed 54 women with a mean age of 53 years (SD 9 ± years). QOL scores in all the women, dipped during the treatment period, in all subscales but improved thereafter and even surpassed the baseline in physical, emotional and breast-specific domains (p < 0.05) at 5 years. At the end of 5 years, there was no statistically significant difference between the MRM and BCT groups in any of the total or domain scores.

CONCLUSION

QOL scores in Indian women did not differ significantly between MRM and BCT in the long term. Both options are acceptable in the study setting.

A checklist for trauma quality improvement meetings: A process improvement study

BACKGROUND

Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM.

METHODS

This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop.

RESULTS

There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7; 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001).

CONCLUSION

This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.

[An independent observatory in Vendée on ST-elevated acute myocardial infarction (the OVISCA Register). A Departmental evaluation of demographic trends, mortality and delays before treatment]

AIM

Mortality from acute myocardial infarction has been falling during the past 30 years. The aim of the study was to evaluate the temporal trends of demographics, mortality rates, and time to treatment in patients admitted for acute ST elevation myocardial infarction (STEMI) in Vendée.

PATIENTS AND METHODS

From 2008 to 2016, 1994 patients hospitalised in CHD Vendée for STEMI <48hours were included. Two groups were compared, 838 patients admitted between 2008 and 2011 (group 1), and 1156 admitted between 2013 and 2016 (group 2).

RESULTS

Between the 2 periods, mean age was comparable (63.8 vs. 64.4 years), the gender ratio decreased (from 3.15 to 2.79 ; P=0.25). The mean duration of hospital stay was 0.8 day shorter (P=0.008). Treatment at discharge was optimum in 97.5% patients versus 92% (P<0.001). Left ventricular ejection fraction was comparable (50.6% vs. 50.2%). There was a non-significant trend to a decrease in hospital mortality (from 6.3% to 4.4%; p=0.12), and 6-month mortality (from 6.9% to 5.9%; P=0.51). There was a reduction in the use of emergency call-outs (74.9% to 68.9%; P<0.01), but an increase in direct presentations from 44% to 48.7% (P<0.05). The time before calling was comparable (2.5hours vs. 2.3hours; P=04.7). The "door-to-balloon" time decreased (0.71 vs. 0.55hour; P<0.001). The mean time between pain and angioplasty increased (5.7 vs. 6.8hours; P<0.05).

CONCLUSIONS

In vendee, from 2011 to 2016, hospital and 6-month mortality of STEMI trend to decrease non-significantly. The door to balloon time decreased, although emergency call-out rates and delays did not. Considerable efforts are still required with respect to patient information and education. Our registry offers an excellent tool to improve practices, the aim being to ensure its integration in the CRAC-France PCI registry.

Protocol of a randomised controlled trial in cardiac surgical patients with endothelial dysfunction aimed to prevent postoperative acute kidney injury by administering nitric oxide gas

INTRODUCTION

Postoperative acute kidney injury (AKI) is a common complication in cardiac surgery. Levels of intravascular haemolysis are strongly associated with postoperative AKI and with prolonged (>90 min) use of cardiopulmonary bypass (CPB). Ferrous plasma haemoglobin released into the circulation acts as a scavenger of nitric oxide (NO) produced by endothelial cells. Consequently, the vascular bioavailability of NO is reduced, leading to vasoconstriction and impaired renal function. In patients with cardiovascular risk factors, the endothelium is dysfunctional and cannot replenish the NO deficit. A previous clinical study in young cardiac surgical patients with rheumatic fever, without evidence of endothelial dysfunction, showed that supplementation of NO gas decreases AKI by converting ferrous plasma haemoglobin to ferric methaemoglobin, thus preserving vascular NO. In this current trial, we hypothesised that 24 hours administration of NO gas will reduce AKI following CPB in patients with endothelial dysfunction.

METHODS

This is a single-centre, randomised (1:1) controlled, parallel-arm superiority trial that includes patients with endothelial dysfunction, stable kidney function and who are undergoing cardiac surgery procedures with an expected CPB duration >90 min. After randomisation, 80 parts per million (ppm) NO (intervention group) or 80 ppm nitrogen (N2, control group) are added to the gas mixture. Test gases (N2 or NO) are delivered during CPB and for 24 hours after surgery. The primary study outcome is the occurrence of AKI among study groups. Key secondary outcomes include AKI severity, occurrence of renal replacement therapy, major adverse kidney events at 6 weeks after surgery and mortality. We are recruiting 250 patients, allowing detection of a 35% AKI relative risk reduction, assuming a two-sided error of 0.05.

ETHICS AND DISSEMINATION

The Partners Human Research Committee approved this trial. Recruitment began in February 2017. Dissemination plans include presentations at scientific conferences, scientific publications and advertising flyers and posters at Massachusetts General Hospital.

TRIAL REGISTRATION NUMBER

NCT02836899.

Smoking abstinence 1 year after acute coronary syndrome: follow-up from a randomized controlled trial of varenicline in patients admitted to hospital

BACKGROUND

Patients who continue to smoke after acute coronary syndrome are at increased risk of reinfarction and death. We previously found use of varenicline to increase abstinence 24 weeks after acute coronary syndrome; here we report results through 52 weeks.

METHODS

The EVITA trial was a multicentre, double-blind, randomized, placebo-controlled trial of varenicline for smoking cessation in patients admitted to hospital with acute coronary syndrome. Participants were randomly assigned (1:1) to receive varenicline or placebo for 12 weeks, in conjunction with low-intensity counselling. Smoking abstinence was assessed via 7-day recall, with biochemical validation using exhaled carbon monoxide. Participants lost to follow-up or withdrawn were assumed to have returned to smoking.

RESULTS

Among the 302 participants, abstinence declined over the course of the trial, with 34.4% abstinent 52 weeks after acute coronary syndrome. Compared with placebo, point estimates suggest use of varenicline increased point-prevalence abstinence (39.9% v. 29.1%, difference 10.7%, 95% confidence interval [CI] 0.01% to 21.44%; number needed to treat 10), continuous abstinence (31.1% v. 21.2%, difference 9.9%, 95% CI -0.01% to 19.8%) and reduction in daily cigarette smoking by 50% or greater (57.8% v. 49.7%, difference 8.1%, 95% CI -3.1% to 19.4%). Varenicline and placebo groups had similar occurrence of serious adverse events (24.5% v. 21.9%, risk difference 2.7%, 95% CI -7.3% to 12.6%) and major adverse cardiovascular events (8.6% v. 9.3%, risk difference -0.7%, 95% CI -7.8% to 6.5%).

INTERPRETATION

Varenicline was efficacious for smoking cessation in this high-risk patient population. However, 60% of patients who received treatment with varenicline still returned to smoking. Trial registration: ClinicalTrials.gov, no. NCT00794573.

A 36-year-old Man with Limb Weakness and Dimness of Vision (NMO)

Neuromyelitis Optica (NMO) previously known as Devic disease is inflammatory disorder of central nervous system characterized by severe immune mediated demyelination and axonal damage predominating targeting optic nerves and spinal cord leading to blindness and paralysis. The spectrum of the disease has expanded based on the specificity of the autoimmune response to the aquaporin-4 (AQP-4) water channel expressed on the end feet of astrocytes in the central nervous system. The coordinated immunological attack against aquaporin-4 is mediated by B & T cells, innate cells including neutrophils and eosinophils and complement system as well as pathogenic antibodies.

A 20 Years Young Lady with Recurrent Convulsion since Childhood (Sturge-Weber Syndrome)

Sturge Weber Syndrome (SWS) is a sporadic neurocutanous disease characterized by facial port wine stain, ocular abnormalities and leptomengealangioma. We present here a 20 year old normotensive, non-diabetic lady hailing from Sarishabari, Jamalur District, Bangladesh got admitted in Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh on 15 July 2018 with the complaints of recurrent convulsion since 3 months of her life, weakness of the right side of the body for same duration according to the statement of the patients mother she was reasonably well until 3 months of her age. The precise pathogenesis is unknown. Clinical feature vary from gentle to full blown sickness with facial stain, seizures and glaucoma.

Lessons for all from the early years of the global surgery initiative

Six elements for future success

Precision Oncology With Radiogenomics: Non-invasive Interrogation of Liver Cancer Genomics to Select Drug Therapy and Monitor Patient Response

Background: Significant intratumoral heterogeneity is present in hepatocellular carcinoma (HCC) and single biopsy samples severely underread the genomic profile of the tumor. This confounds drug development in HCC and makes it extremely challenging to stratify and prognosticate patients to select therapy on the basis of genomic biomarkers. Multiregion sampling of surgically resected HCC allows for these intratumoral heterogeneity to be unraveled and this is currently carried out in our prospective PLANET (Precision Medicine in Liver Cancer across an Asia-Pacific Network) program. However, multiregion sampling is not practical in unresectable HCC cases, which comprise 80% of the disease burden. Radiogenomics studies on liver, lung and head-and-neck cancers have established the capability of radiomics analysis in capturing intratumor heterogeneity with the identification of radiomics signatures that are representative of underlying gene expression patterns. Aim: On this basis, our PLANET program has adopted a radiogenomics approach to characterize the intratumoral heterogeneity in HCC. Methods: This approach will leverage on the correlation of distinctive imaging traits in CT scans against the gene expression profiles of surgically resected HCC patients. Our PLANET program and the data-science enterprise Holmusk have embarked on close collaborative efforts to develop an algorithm that characterizes intratumoral heterogeneity based on distinctive traits in the CT scans. Results and conclusion: The development of such an algorithm is potentially ground-breaking as it allows for the noninvasive interrogation of liver cancer genomics and prognostication of HCC patients. This allows the easy screening of patients for therapeutic targets in vivo and will significantly improve the selection of drug therapy and monitoring of therapeutic response in HCC.

Spectrum of connectivity fluctuations including the effect of activity-dependent feedback

The spatiotemporal spectrum of feedback-driven fluctuations of brain connectivity is investigated using nonlinear neural field theory of the corticothalamic system. Weakly nonlinear dynamics of neural feedbacks are expanded in terms of first order perturbations of neural activity relative to a fixed point. Susceptibilities are used to quantify the change in connectivity per unit change in presynaptic or postsynaptic activity caused by nonlinear feedbacks such as facilitation, depression, sensitization, potentiation, and the effects of discrete eigenmode structure are included for a spherical brain geometry. Spectral signatures such as resonances are identified that allow the presence of particular presynaptic and postsynaptic feedback effects to be inferred. These include additional resonances at high frequencies and shifts of existing spectral peaks, mostly visible in the lowest spatial modes of the response.

Impella Placement Guided by Echocardiography Can Be Used as a Strategy to Unload the Left Ventricle During Peripheral Venoarterial Extracorporeal Membrane Oxygenation

OBJECTIVE

At the authors' institution, before 2015, patients cannulated for peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) did not undergo left ventricular (LV) decompression with the use of an LV vent. After 2015, the authors' institution began using the Impella device to vent the left ventricle in patients on VA-ECMO. The authors hypothesized that survival outcomes would improve in patients on VA-ECMO with the use of an Impella for LV venting.

DESIGN

Retrospective, chart based review study.

SETTING

Single center, university-based hospital.

PARTICIPANTS

All adult patients at the authors' institution who required VA-ECMO between January 2015 and May 2017.

INTERVENTION

An Impella (Abiomed, Danvers, MA) device was placed percutaneously in patients cannulated for VA-ECMO as a mechanism to provide LV venting and decompression, therefore unloading the heart.

MEASUREMENTS AND MAIN RESULTS

Manual chart review was conducted, and a survival analysis was performed. It was observed that patients on VA-ECMO in whom an Impella was implanted had improved survival and an improvement in LV function as demonstrated by echocardiography compared with patients maintained on VA-ECMO alone.

CONCLUSIONS

Patients on VA-ECMO plus Impella implantation demonstrated improved survival compared with patients treated with VA-ECMO alone. Key echocardiographic characteristics such as improved LV function after Impella placement and LV cavity size reduction during therapy may help predict those patients who may benefit most from this cannulation strategy.