Impact of unemployment on cardiovascular mortality in united states: a nationwide county-level analysis 2010–2019

Background

Unemployment has been linked with a myriad of adverse health outcomes; however, its population-level impact on cardiovascular mortality (CVM), particularly amongst various demographic subgroups, remains understudied.

Purpose

To determine the impact of county unemployment levels on CVM rates, in overall and between different demographic subgroups.

Methods

We utilized the CDC WONDER database tool to retrieve county-level CVM rates for U.S. counties between 2010 and 2019. The County Health Rankings project was used to retrieve data on unemployment levels in each county as well as other characteristics used in an adjusted multivariate model. Generalized linear mixed models using Poisson regression were used to estimate the impact of unemployment on county-level CVM using relative (incidence rate ratios; IRR) and absolute (additional yearly deaths; AYD) measures.

Results

From 2010 to 2019, a total of 2904 U.S. counties (64.2% white; 50.81% female) with data available on CVM and unemployment levels were analyzed. In a multivariate model adjusted for demographic composition, CV risk, socioeconomic, environmental, and healthcare-access factors, unemployment was significantly associated with higher levels of CVM (IRR: 1.026; 95% CI: 1.018 to 1.033; 6.00 AYD). The relative impact of unemployment was strongest in elderly Blacks (IRR: 1.051; 95% CI: 1.029 to 1.074), middle-aged whites (IRR: 1.050; 95% CI: 1.032 to 1.067), and middle-aged females (IRR: 1.046; 95% CI: 1.018 to 1.075). The absolute impact of unemployment was highest in elderly Blacks (AYD: 94.70), elderly Whites (AYD: 35.30), and elderly females (AYD: 32.70). On a relative basis, the impact was more pronounced in the middle-aged (IRR: 1.030; 95% CI: 1.015 to 1.044) compared to the elderly (IRR: 1.022; 95% CI: 1.014 to 1.030), females (IRR: 1.026; 95% CI: 1.017 to 1.036) compared to males (IRR: 1.022; 95% CI: 1.014 to 1.031), and Blacks (IRR: 1.036; 95% CI: 1.016 to 1.057) compared to Whites (IRR: 1.030; 95% CI: 1.022 to 1.038).

Conclusion(s)

Unemployment is significantly associated with county-level CVM, and this impact is most pronounced in vulnerable demographic subgroups, namely females and Blacks. Efforts to reduce unemployment levels may significantly lower the burden of cardiovascular disease, particularly in groups most strongly affected by health disparities.

Funding Acknowledgement

Type of funding sources: None.

Adding troponin to echocardiography improves preoperative abscess detection in infective endocarditis. A REMOVE Trial analysis

Background

Detection of cardiac abscess in patients with infective endocarditis (IE) is important for surgical planning and decision-making. While transesophageal echocardiography (TEE) is the method of choice for abscess detection, in many cases uncertainty remains. Since IE abscesses often affect ventricular muscle, biomarker release may be a helpful adjunct for abscess detection.

Purpose

We assessed the accuracy of TEE and the value of combining it with preoperative measurement of cardiac Troponin (cTn) in the diagnosis of abscess, using surgical inspection as a reference.

Methods

Data collected in the electronic clinical report form for patients included in the prospective, multicenter, randomized, controlled trial (REMOVE Trial) were analyzed. Continuous variables are presented as median (25th–75th percentile) and categorical data as absolute and relative frequencies. The diagnostic performance of TEE was identified by comparing preoperative TEE findings with intraoperative findings. The concordance rate is expressed as a percentage. Receiver operating characteristic (ROC) curve was used to assess the ability of cTn to predict the presence of abscess intraoperatively. Area under curve (AUC) with 95% confidence interval as well as sensitivity and specificity are provided as measures of accuracy. Youden index was used to estimate an optimal cut-off value for cTn.

Results

Among the 282 patients included, 84 had abscesses detected intraoperatively. The sensitivity and specificity of TEE to detect abscess were 58.3% and 86.4%, respectively. cTn-I and cTn-T were measured preoperatively in 113 and 96 patients, respectively. Median cTn-I in patients with abscess was 132 pg/ml (interquartile range (IQR): 54–1528) vs 53 pg/ml (IQR: 17–250) in patients without abscess, p=0.002. Median cTn-T in patients with abscess was 941 pg/ml (IQR: 387–1527) vs 697 pg/ml (IQR: 282–1423) in patients without abscess, p=0.353. The incidence of recent preoperative myocardial infarction was not different between patients with or without abscess (7.1% vs 5.6%, respectively, p=0.593). The AUC for predicting abscess was 0.69 (95% CI: 0.57 to 0.80, p=0.002) and 0.56 (95% CI: 0.43 to 0.69, p=0.353) for preoperative cTn-I and cTn-T, respectively. Optimal cut-offs according to the Youden index are 38 pg/ml for cTn-I and 1632 pg/ml for cTn-T. By adding preoperative cTn-I or cTn-T to the TEE findings, the AUC increased to 0.82 (95% CI: 0.73 to 0.91, p<0.001) and 0.72 (95% CI: 0.59 to 00.84, p=0.001), respectively.

Conclusion

The results suggest that using TEE alone is a poor method for abscess detection in IE. Adding preoperative troponin values to TEE findings significantly improved IE abscess detection.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Federal Ministry of Education and Research (BMBF), Germany

Prognostic relevance of mitral regurgitation at different follow-up timepoints after transcatheter aortic valve implantation (TAVI): implications for therapeutic decision making?

Background

Transcatheter aortic valve implantation (TAVI) has developed rapidly in the last decade and is now recommended as state-of-the-art treatment for elderly patients suffering from severe symptomatic degenerative aortic stenosis (AS). The extent of mitral regurgitation (MR) following TAVI is likely to be of prognostic relevance. This raises the question whether treating MR following TAVI improves outcome of patients with significant MR.

Purpose

The current study was aimed to elucidate the prognostic value of MR at different follow-up (FU) timepoints after TAVI in a prospective real-world single-center registry study.

Methods

A total of 445 patients with severe AS, which were treated by transfemoral TAVI, were included and a wide range of clinical, laboratory, functional and imaging parameters were prospectively assessed. Mortality was recorded at 30 days, 1 year and 2 years after TAVI. Complete FU data including echocardiography were available at 6 to 8 weeks (n=334) as well as 6 months (n=235) after TAVI.

Results

All patients (mean age: 78.7±7.3 years, 52% female, mean STS score: 5±3.9%) were successfully treated by transfemoral TAVI using balloon- or self-expanding prostheses and showed mortality rates of 3.6% after 30 days, 16.4% after 1 year and 22.6% after 2 years. Moderate or severe (relevant) MR was detectable in 39% of the patients at baseline, in 27% of patients after 6 weeks (p=0.001) and in 28% of patients after 6 months (p=0.036, compared to baseline). Multivariate analysis identified independent predictors of 2-year mortality: clinical frailty scale and PAPsys at 6 to 8 weeks post-TAVI as well as BNP and relevant MR 6 months post TAVI. Among those parameters, MR after 6 months was the strongest predictor of long-term mortality (OR 3.192, CI 0.971–10.487, p=0.056). Kaplan-Meier survival analysis displayed significantly worse 2-year survival rates in patients suffering from relevant MR at 6 months (12.1% versus 4.8%, p=0.042).

Conclusions

Taken together, this real-life single-center experience underlines the prognostic value of relevant MR 6 months after TAVI with respect to long-term survival. Interestingly, MR was not predictive at the 6 to 8 weeks FU suggesting that early remodeling includes MR with prognostic relevance in those patients. Whether MR treatment, e.g., by transcatheter edge-to-edge repair, will improve patient outcomes post-TAVI has to be tested in prospective trials.

Funding Acknowledgement

Type of funding sources: None.

Tricuspid regurgitation and atrial fibrillation at baseline independently predict two-year survival after transcatheter aortic valve implantation (TAVI)

Background

Transcatheter aortic valve implantation (TAVI) is the accepted state-of-the-art treatment for elderly patients suffering from severe symptomatic aortic stenosis (AS). Co-morbidities at baseline are of great impact not only for individual peri-procedural risk stratification but also for the determination of long-term prognosis. The latter is of certain clinical interest, since a variety of co-existing disorders can be effectively treated in addition to TAVI.

Purpose

The current study aimed to elucidate the prognostic value of a wide range of baseline characteristics and co-morbidities with respect to long-term survival of TAVI patients in a prospective real-world single-center registry study.

Methods

A total of 445 patients with severe AS, which were treated by transfemoral TAVI, were included. A wide range of clinical, laboratory, functional and imaging parameters were prospectively assessed at baseline prior to TAVI. Mortality was recorded at 30 days, 1 year and 2 years after TAVI.

Results

The mean age of patients in this typical TAVI cohort was 78.7±7.3 years, 52% were female and the mean STS score was 5±3.9%. The mortality rates were as follows: 3.6% after 30 days, 16.4% after 1 and 22.6% after 2 years. Multivariate analysis could identify the following independent predictors of 2-year mortality assessed at baseline: sex, age, AS entity other than high-gradient, atrial fibrillation (Afib), renal function, relevant TR, systolic pulmonary artery pressure (PAPsys) and six-minute walk distance (SMWD). Among those, the strongest predictive value could be shown for Afib (OR 2.505, CI 1.509–4.157, p<0.001) and TR (OR 2.179, CI 1.105–4.299, p=0.025). Kaplan-Meier survival analysis displayed significantly worse 2-year survival rates in patients suffering from relevant TR (31.6% versus 17.4%, p<0.001) and Afib (29.4% versus 14.8%, p<0.001).

Conclusions

Taken together, the results of the current study demonstrate the prognostic value of cardiovascular co-morbidities assessed prior to TAVI. We identified relevant TR and Afib as the strongest independent predictors of long-term mortality in our cohort. Since both conditions are effectively treatable, special emphasis should be placed on the question, which patient might benefit from treatment, e.g., by transcatheter edge-to-edge repair of TR or rhythm control, in addition to TAVI.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Else Kröner-Fresenius-Stiftung, Research Program “Else Kröner-Forschungskolleg AntiAge”

Burden and disparities in cardiovascular mortality rates associated with obesity prevalence in United States: county-level analysis from 2010 to 2019

Background

Obesity is a grave public health threat linked to high morbidity and mortality rates. A significant rise in obesity rates amongst U.S. adults and worldwide has been observed in recent decades. Although associations between obesity and cardiovascular mortality (CVM) are well-known, impact and disparities in CVM attributable to obesity at a nationwide community level, aren't well defined.

Purpose

At county level, we sought to evaluate the independent impact of adult obesity on CVM in overall population and within different age, sex, and race/ethnic subgroups.

Methods

Age-adjusted CVM rates (ACVM) between 2010 to 2019, were obtained using Wide-ranging Online Data for Epidemiologic Research tool of Center for Disease Control (CDC). Using the Behavioral risk Factors Surveillance System (BRFSS), obesity rates per county was assessed as the percentage of adult population (age ≥20) that reports a body mass index ≥30 kg/m2. BRFSS, CDC Diabetes Interactive Atlas, census population estimates, environmental public health network and health county ranking project databases, were utilized to acquire county data of demographics, CV risk, socio-environmental, and health care access factors. Poisson multivariate generalized linear mixed models were employed to assess incidence rate ratios (IRR) of ACVM associated with obesity rates. To evaluate the absolute impact of obesity on ACVM, additional yearly deaths (AYD) per 100,000 individuals were calculated. All study analysis were weighted for the relevant county baseline population.

Results

Among 307,045,647 residents (50% women, 12% non-Hispanic blacks, 24% aged 45–64) lived at 2904 US counties in 2010, total 8,157,571 (2.7%) CV deaths occurred between 2010–2019. In fully adjusted model*, high obesity rates significantly associated with high ACVM (IRR: 1.015; 95% CI: 1.008 to 1.022), that translated to 3.5 AYD per 100,000 individuals. In a subgroup analysis, obesity rates associated with a relatively higher ACVM among overall middle aged adults [45 to 64] (IRR: 1.028; 95% CI: 1.018 to 1.037) versus elderly [≥65] (IRR: 1.013; 95% CI: 1.006 to 1.020), and in males (IRR: 1.018; 95% CI: 1.010 to 1.026) versus females (IRR: 1.014; 95% CI: 1.006 to 1.022), and in Hispanics (IRR: 1.035; 95% CI: 1.005 to 1.065) versus non-Hispanic Whites (IRR: 1.020; 95% CI: 1.012 to 1.027). Interestingly, middle aged adults had higher ACVM IRRs as compared to elderly, among males (IRR: 1.022), females (IRR: 1.039), and non-Hispanic Whites (IRR: 1.044) (Figure).

Conclusions

Obesity prevalence is independently associated with high ACVM among different age, sex, and race/ethnic groups, and this impact is most pronounced in Hispanics and the middle-aged group of females and non-Hispanic Whites. More research is needed to further uncover the mechanisms leading to these observations a long with community-level interventions to reduce the burden of this ongoing epidemic, in overall and most impacted population groups.

Funding Acknowledgement

Type of funding sources: None.

Exploring determinants of antimicrobial prescribing behaviour: a qualitative study using the Theoretical Domains Framework

Introduction

Few qualitative studies have explored determinants of antimicrobial prescribing behaviour in hospitals, and none has made reference to behavioural theories. An understanding of these determinants is required for the successful development and implementation of behaviour change interventions (BCIs) in this area.

Aim

To explore the determinants of clinicians’ antimicrobial prescribing behaviour, using the Theoretical Domains Framework (TDF; a framework of behavioural theories).

Methods

This work was part of a multi-phase explanatory, sequential mixed methods PhD programme of research. This qualitative part involved semi-structured, online (video) interviews via a videoconferencing software programme (Zoom) with clinicians (doctors and pharmacists) based in 12 Hamad Medical Corporation hospitals in Qatar. Clinicians were sampled purposively in strata of gender, profession, years of experience and area of practice. The interview schedule was developed based on a review of published literature (1), previous findings of quantitative research (2) and the TDF to ensure comprehensive coverage of key determinants (including barriers and facilitators) related to clinicians’ antimicrobial prescribing behaviour. Interviews were conducted from December 2020 to February 2021, audio-recorded, transcribed and independently analysed by two research team members using the TDF as an initial coding framework.

Results

Data saturation was achieved after interviewing eight doctors and eight pharmacists from a range of areas of practices and with a variety of experiences. A number of themes, linked to ten TDF domains, were identified as determinants of antimicrobial prescribing behaviour and these determinants were interrelated. In-depth analysis identified several barriers and facilitators that may contribute to inappropriate or appropriate antimicrobial prescribing. Main barriers identified were around hospital guidelines and electronic system deficiencies (environmental context and resources), gaps in the knowledge in relation to guidelines and appropriate prescribing (knowledge), restricted roles/responsibilities of microbiologists and pharmacists (professional role and identity), uncomfortable antimicrobial prescribing decisions (memory, attention and decision processes), as well as professional hierarchies and poor multidisciplinary teamworking/relationships (social influences). “Sometimes, the barrier would be the ego of senior doctors who refuse our evidence-based recommendation and depend on their clinical judgement or experience” (Pharmacist 470, Cardiology). Key facilitators highlighted included guidelines compliance goals and intentions, and the beliefs of consequences of appropriate or inappropriate prescribing. Further education and training sessions, and some changes to guidelines, including accessibility were also considered essential. “We need to seriously consider getting an antibiotic guidelines app which is downloaded to clinicians’ mobile phones. The mobile app is handy, you can access it anytime even at the patient’s bedside” (Doctor 514, Microbiology).

Conclusion

This qualitative study, using a theoretically based approach, has identified that antimicrobial prescribing in hospitals is a complex process influenced by a broad range of behavioural determinants that described specific barriers and facilitators. The in-depth understanding of this complexity provided by this phase of the research may contribute to the design and development of theoretically based BCIs to improve clinicians’ antimicrobial prescribing. Limitations include data collected with online interviews due to the Covid-19 restrictions. This may have excluded some clinicians who did not feel comfortable with or have access to the technology required.

References

(1) Talkhan H, Stewart D, Mcintosh T, Ziglam H, Abdulrouf P, Al-Hail M et al. The use of theory in the development and evaluation of behaviour change interventions to improve antimicrobial prescribing: a systematic review. Journal of Antimicrobial Chemotherapy. 2020;75(9):2394-2410.

(2) Talkhan H, Stewart D, McIntosh T, Ziglam H, Abdulrouf P, Al-Hail M et al. Using the Theoretical Domains Framework to investigate clinicians’ behavioural determinants of antimicrobial prescribing in Qatar. International Journal of Pharmacy Practice. 2021;29(1):i20-i22.

The impact of establishing a regional infective endocarditis (IE) network on pre-operative IE-related complications and on post-operative outcome

Background

Infective endocarditis (IE) requires a high degree of suspicion and advanced level of multidisciplinary management. In 2015, the European guidelines recommended the formation of an endocarditis-team (ET) for optimal treatment of IE. In 2011, we already established an ET within the hospital that was only consulted on demand for certain patients. Since 2015, ET has been increasingly involved in the management of almost all patients with IE. In addition, we established in 2015 a statewide endocarditis- (E) network for the referring hospitals.

Purpose

We investigated the effect of E-network on reducing referral latency and pre-operative IE-related complications. We also investigated the adherence to the ET management recommendations in our hospital and its impact on post-operative stroke and mortality.

Methods

We retrospectively analyzed data from patients operated for IE in our center between 01/2007 and 03/2018. We conducted univariate analysis using Chi-square or Fisher's exact test, Multivariate logistic regression models for in-hospital mortality and post-operative stroke, and Kaplan-Meier estimate of 5-years survival.

Results

Among 630 patients operated for IE in our center, 409 (65%) underwent surgery in the 1st era before 12/2014. S. aureus IE was more frequent in the second era (34% vs 25%, p<0.001). The median time from the onset of symptoms to referral in the 2nd era was halved compared to the first one [7 days (IQR 2–19) vs 15 days (IQR 6–35)]. Patients in the 2nd era were admitted with less IE-related complications, i.e. less preoperative stroke (14% vs 27%, p<0.001), less heart failure (45% vs 69%, p<0.001) less cardiac abscesses (24% vs 34%, p=0.018), less acute renal insufficiency requiring hemodialysis (8% vs 14%, p=0.026). The lack of ET management recommendations was an independent predictor for in-hospital mortality (adjusted OR: 2.13, 95% CI: 1.27–3.53, p=0.004) and post-operative stroke (adjusted OR: 2.23, 95% CI: 1.12–4.39, p=0.02), and was associated with worse 5-years survival (59% compared to 40%, log rank<0.001).

Conclusion

Endocarditis-network led to earlier referral of patients, which resulted in less IE-related complications on admission. Lack of ET management recommendations was an independent predictor for post-operative stroke, in-hospital mortality and was associated with worse 5-years survival.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Using the Theoretical Domains Framework to investigate clinicians’ behavioural determinants of antimicrobial prescribing in Qatar

Introduction

A recent systematic review by Talkhan et al demonstrated the need for theoretically based behaviour change interventions in this area. [1] For development of such complex interventions, emphasis should be placed on using theory to systematically identify behavioural determinants of antimicrobial prescribing.

Aim

To identify and quantify clinicians’ behavioural determinants of antimicrobial prescribing in Qatar.

Methods

This cross-sectional survey is part of a multi-phase explanatory, sequential mixed methods PhD project in Qatar. Questionnaires were distributed (online and paper based) to all doctors (~4,000) and pharmacists (~400) within Hamad Medical Corporation (HMC, the main healthcare provider). The questionnaire was developed with reference to the Determinants of Implementation Behaviour Questionnaire (a generic questionnaire derived from the 14 theoretical domains of the Theoretical Domains Framework, TDF). [2] Each item was presented as a 5-point Likert scale (scored 5=Strongly agree to 1=Strongly disagree). Personal and practice demographics were also collected for data contextualisation. The draft questionnaire was reviewed for face/content validity by an expert panel of six researchers in Qatar and the UK with experience in the use of the TDF, followed by ‘Think aloud’ testing and piloting. Analysis investigated the behavioural determinants and influential factors through descriptive, principal component analysis (PCA) and inferential analysis. Ethics approval was granted from a UK university and HMC.

Results

In total, 535 responses were received, 339 (63.4%) from doctors and 196 (36.6%) from pharmacists. Respondents were predominantly male, 346 (64.7%). Just over half (n=285, 53.3%) had ≤ 5 years’ experience as health professionals. PCA showed a three component (C) solution with components incorporating a number of questionnaire items labelled: ‘Guidelines compliance’ (C1 with 8 items), ‘Influences on prescribing’ (C2 with 7 items) and ‘Self-efficacy’ (C3 with 5 items) in prescribing/recommendation activity. A scale score for each respondent was calculated through summation of Likert scores for the relevant questionnaire items within each component. These scales had high internal reliability (Cronbach’s alpha all >0.7) showing consistency in response between component items indicating statistical appropriateness for developing scales. The median score (possible scale range, midpoint) for each scale was C1, 32 (8 to 40, 24), C2, 26 (7 to 35, 21) and C3, 20, (5 to 25, 15). By way of example Table 1 shows levels of agreement for items in C2. This shows lower levels of agreement than C1 scale with the median scale score (26) closer to the midpoint (21) indicating that respondents had less positive views. Inferential analysis using these scale scores and free text analysis is in progress.

Conclusion

A theoretical basis was used throughout providing insights to behavioural determinants for the development of a theory-based behaviour change intervention. Preliminary results suggest that social influences, staff development and quality monitoring may be useful targets for behaviour change interventions to improve antimicrobial prescribing practice. Limitations include potential social desirability bias and focus on one healthcare organisation/country in the Middle East which may limit generalisability of findings. More in-depth exploration is required to select and test appropriate linked theory-based behaviour change techniques.

References

1. Talkhan H, Stewart D, McIntosh T, Ziglam H Palli Valapila, A; Moza Sulaiman H, Diab M, Cunningham S. The use of theory in the development and evalu​ation of behaviour change interventions to improve antimicrobial prescribing: a systematic review. J Antimicrob Chemother. 2020;75(9):2394–2410, Available from https://doi.org/10.1093/jac/dkaa154 [Accessed 12 Oct 2020].

2. Huijg JM, Gebhardt WA, Dusseldorp E, Verheijden MW, van der Zouwe N, Middelkoop BJ, Crone MR. Measuring determinants of implementation behaviour: psychometric properties of a questionnaire based on the Theoretical Domains Framework. Implement. Sci. 2014;9(1):33.

S. aureus endocarditis: Clinical aspects and experimental approaches

Infective endocarditis (IE) is a life-threatening disease, caused by septic vegetations and inflammatory foci on the surface of the endothelium and the valves. Due to its complex and often indecisive presentation the mortality rate is still about 30%. Most frequently bacterial microorganisms entering the bloodstream are the underlying origin of the intracardiac infection. While the disease was primarily restricted to younger patients suffering from rheumatic heart streptococci infections, new at risk categories for Staphylococcus (S.) aureus infections arose over the last years. Rising patient age, increasing drug resistance, intensive treatment conditions such as renal hemodialysis, immunosuppression and long term indwelling central venous catheters but also the application of modern cardiac device implants and valve prosthesis have led to emerging incidences of S. aureus IE in health care settings and community. The aetiologic change has impact on the pathophysiology of IE, the clinical presentation and the overall patient management. Despite intensive research on appropriate in vitro and in vivo models of IE and gained knowledge about the fundamental mechanisms in the formation of bacterial vegetations and extracardiac complications, improved understanding of relevant bacterial virulence factors and triggered host immune responses is required to help developing novel antipathogenic treatment strategies and pathogen specific diagnostic markers. In this review, we summarize and discuss the two main areas affected by the changing patient demographics and provide first, recent knowledge about the pathogenic strategies of S. aureus in the induction of IE, including available experimental models of IE used to study host-pathogen interactions and diagnostic and therapeutic targets. In a second focus we present diagnostic (imaging) regimens for patients with S. aureus IE according to current guidelines as well as treatment strategies and surgical recommendations.

Metabolomic profiling in patients undergoing Off-Pump or On-Pump coronary artery bypass surgery

Background

Coronary artery bypass surgery can be performed without (Off-Pump) or with cardiopulmonary bypass (On-Pump). Extracorporeal circulation and cardioplegic arrest may cause alterations in the plasma metabolome. We assessed metabolomic changes in patients undergoing On-Pump or Off-Pump coronary artery bypass surgery.

Methods

We assessed five analyte classes (41 acylcarnitines, 14 amino acids, 92 glycerophospholipids, 15 sphingolipids, sugars, lactate) using a mass-spectrometry-based kit (Biocrates AbsoluteIDQ® p150) in paired arterial and coronary sinus blood obtained from 10 consecutive On-Pump and 10 Off-Pump patients. Cardioplegia for On-Pump was warm blood Calafiore. On-Pump outcomes were corrected for hemodilution through crystalloid priming.

Results

Demographic data were equal in both groups with normal ejection fraction, renal and liver function. Patients received 2.25 ± 0.64 bypass grafts. All postoperative courses were uneventful. Of 164 measured metabolites, only 13 (7.9%) were altered by cardiopulmonary bypass. We found more long-chain acylcarnitines Off-Pump and more short-chain acylcarnitines On-Pump. Glycerophospholipids showed lower concentrations On-Pump and arginine (as the only different amino acid) Off-Pump. Interestingly, plasma arginine (nitric oxide precursor) concentration at the end of surgery correlated inversely with postoperative vasopressor need (r = −0.7; p < 0.001). Assessing arterial/venous differences revealed phosphatidylcholine-production and acylcarnitine-consumption. These findings were unaffected by cardiopulmonary bypass, cardioplegia or temporary vessel occlusion during Off-Pump surgery.

Conclusions

Cardiopulmonary bypass and warm blood cardioplegia cause only minor changes to the metabolomic profile of patients undergoing coronary artery bypass surgery. The observed changes affected mainly acylcarnitines. In addition, there appears to be a relationship between arginine and vasopressor need after bypass surgery.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-017-0518-1) contains supplementary material, which is available to authorized users.

Operative treatment of calcaneal fractures: improved outcomes and low complications rates with a strict management protocol

This is a retrospective review of 80 intra-articular calcaneal fractures treated with open reduction and internal fixation by a specialist team under supervision of a single surgeon in a tertiary centre between 2005 and 2014. The fractures were evaluated with plain radiography and computed tomography, and graded using the Eastwood-Atkins classification. A lateral approach was used and all fractures were fixed with calcaneal plates. All patients had clinical and radiological follow-up. Clinical assessment included foot and ankle disability index, SF-36^® and Kerr-Atkins scores. The mean follow-up duration was 72 months (range: 12-130 months). The mean age of patients was 49 years (range: 17-73 years). There were three open fractures and eight patients had other injuries. The mean Bohler's angle improved from 6° preoperatively to 26° postoperatively. The mean foot and ankle disability index score was 78.62, the mean SF-36^® scores were 45.5 (physical component) and 52.6 (mental component), and the mean Kerr-Atkins score was 72 (range: 36-100). Early complications included one case of screw protrusion in the subtalar joint (which warranted a repeat procedure), one sural nerve injury and one wound breakdown, which healed with non-operative measures. Twelve patients had symptomatic subtalar joint osteoarthritis. Four of these had subtalar fusion. We believe that our strict protocols of patient selection, intraoperative and postoperative management produced long-term results comparable with those in the peer reviewed literature.

Production and characterization of monoclonal antibodies specific for canine CD138 (syndecan-1) for nuclear medicine preclinical trials on spontaneous tumours

We isolated 11 antibodies specific for canine CD138 (cCD138) to validate the interest of CD138 antigen targeting in dogs with spontaneous mammary carcinoma. The affinity of the monoclonal antibodies in the nanomolar range is suitable for immunohistochemistry and nuclear medicine applications. Four distinct epitopes were recognized on cCD138 by this panel of antibodies. CD138 expression in canine healthy tissues is comparable to that reported in humans. CD138 is frequently expressed in canine mammary carcinomas corresponding to the human triple negative breast cancer subtype, with cytoplasmic and membranous expression. In canine diffuse large B-cell lymphoma, CD138 expression is associated with the 'non-germinal center' phenotype corresponding to the most aggressive subtype in humans. This homology of CD138 expression between dogs and humans confirms the relevance of tumour-bearing dogs as spontaneous models for nuclear medicine applications, especially for the evaluation of new tumour targeting strategies for diagnosis by phenotypic imaging and radio-immunotherapy.