Echocardiographic predictors of outcome after isolated tricuspid valvular surgery

Funding Acknowledgements

Type of funding sources: None.

Background

Right ventricular (RV) function is one factor influencing outcome after isolated tricuspid valve surgery (ITVS). As it is highly load dependant, its echocardiographic assessment requires a multiparametric analysis.

Purpose

To assess prognostic value of RV echocardiographic parameters among patients undergoing ITVS.

Methods

Preoperative echocardiograms were retrospectively reviewed in 75 patients (mean age 54 ± 17 years) who underwent ITVS between 2007 and 2020. We assessed classical parameters of RV load, morphology and function, and calculated a load-remodeling-function index (LRFI) combining load (using tricuspid regurgitation time-velocity integral), remodeling (using ratio of RV diameter / length) and function (using strain rate (SR)). Those parameters were compared between alive and dead patients at 1-year follow-up.

Results

Mortality rate was 17.3% at 1 year and 22.7% at 5 years. Among standard RV function parameters, only S’ and SR were significantly lower in dead than in alive patients at 1 year.

LRFI was significantly higher in dead patients at 1-year. By analysis of ROC curve, LRFI (AUC 0.823 [0.678-0.968]; p = 0.002) was the best predictor of death at 1 year.

When associating a clinical variable (pre-existing right heart failure (RHF)) and LRFI, Kaplan Meier curves showed significantly higher mortality in patients with both RHF and altered LRFI.

Conclusion

Global RV analysis using a parameter combining load, remodeling and function may help in the prognostic assessment of patients undergoing ITVS, in addition to the presence of RHF.

Symptomatic improvement after mesh removal: a prospective longitudinal study of women with urogynaecological mesh complications

OBJECTIVE

To compare clinical characteristics and outcomes in patients undergoing excision of polypropylene urogynaecological mesh for pain, mesh exposure or both.

DESIGN

Prospective, longitudinal cohort.

SETTING

Academic tertiary referral centre.

POPULATION

Women undergoing complete vaginal mesh excision for mesh exposure and/or pain.

METHODS

Clinical and patient-reported outcomes assessing pain (visual analog scale, VAS), bother (Pelvic Floor Distress Inventory, PFDI) and functional impact (Pelvic Functional Impact Questionnaire, PFIQ) were collected at baseline, 6, 12 and 24 months after complete mesh excision. Outcomes were compared by mesh type (sling, prolapse [transvaginal or sacrocolpopexy mesh], both) and complication (pain, exposure, both).

MAIN OUTCOME MEASURES

'Much better' or 'Very much better' on Patient Global Impression of Improvement (PGI-I) up to 2 years after removal.

RESULTS

Of 173 women, 48 underwent removal for pain, 27 for exposure and 98 for exposure plus pain. 'Moderate to severe' baseline symptoms were reported by 75%; the most prevalent and severe symptom was dyspareunia. Patients with pain alone were most bothered (PFDI median 234.2, interquartile range 83, P = 0.02) and had the highest functional impact (PFIQ median 181, interquartile range 138, P < 0.001). After excision, only 33.3% of women with pain alone reported 'improved' symptoms (PGI-I), versus 73.9% with exposure, 58.3% with exposure plus pain (P = 0.03) with no differences in PGI-I by mesh type. VAS scores decreased in all groups, but PFDI and PFIQ did not improve in pain patients.

CONCLUSIONS

In women experiencing a pain complication after urogynaecological mesh insertion, mesh removal often does not improve symptoms.

TWEETABLE ABSTRACT

Only 33% of women with pain complications have improved symptoms after urogynaecological mesh removal.

Pulmonary Embolism in Covid-19 patients: A French Multicentre Cohort Study

Background

While pulmonary embolism (PE) appears to be a major issue in Covid-19, data remain sparse.

Purpose

We aimed to describe the risk factors and baseline characteristics of patients with PE in a large cohort of Covid-19 patients.

Methods

In a retrospective multicentric observational study, we included consecutive hospitalised patients for Covid-19. Patients without computed tomography pulmonary angiography (CTPA)-proven PE diagnosis, those who were directly admitted to an intensive care unit (ICU), and those still hospitalised without PE experience were excluded.

Results

Among 1240 patients (58.1% men, mean age 64 ± 17 years), 103 (8.3%) patients had PE confirmed by CTPA. The ICU transfer requirement and mechanical ventilation requirement were significantly higher in the PE group (P < 0.001 and P < 0.001, respectively). In an univariable analysis, traditional venous thromboembolic risk factors were not associated with PE (P > 0.05), while patients under therapeutic-dose anticoagulation before hospitalisation or prophylaxis-dose anticoagulation introduced during hospitalisation had lower PE occurrence (OR 0.40, 95%CI(0.14-0.91); P = 0.04 and OR 0.11, 95%CI(0.06-0.18); P < 0.001, respectively). In a multivariable analysis, the following variables (also statistically significant in univariable analysis) were associated with PE: male gender (OR 1.03, 95%CI(1.003-1.069); P = 0.04), anticoagulation with prophylaxis-dose (OR 0.83, 95%CI(0.79-0.85), P < 0.001) or therapeutic-dose (OR 0.87, 95%CI(0.82-0.92), P < 0.001), C-reactive protein (OR 1.03, 95%CI(1.01-1.04), P = 0.001) and time from symptom onset to hospitalisation (OR 1.02, 95%CI(1.006-1.038), P = 0.002) (Table 1).

Conclusion

Pulmonary embolism risk factors in Covid-19 context do not include traditional thromboembolic risk factors but rather independent clinical and biological findings at admission, including a major contribution to inflammation.

Systematic review and consensus definitions for standardised endpoints in perioperative medicine: postoperative cancer outcomes

BACKGROUND

The Standardising Endpoints for Perioperative Medicine group was established to derive an appropriate set of endpoints for use in clinical trials related to anaesthesia and perioperative medicine. Anaesthetic or analgesic technique during cancer surgery with curative intent may influence the risk of recurrence or metastasis. However, given the current equipoise in the existing literature, prospective, randomised, controlled trials are necessary to test this hypothesis. As such, a cancer subgroup was formed to derive endpoints related to research in onco-anaesthesia based on a current evidence base, international consensus and expert guidance.

METHODS

We undertook a systematic review to identify measures of oncological outcome used in the oncological, surgical, and wider literature. A multiround Delphi consensus process that included up to 89 clinician-researchers was then used to refine a recommended list of endpoints.

RESULTS

We identified 90 studies in a literature search, which were the basis for a preliminary list of nine outcome measures and their definitions. A further two were added during the Delphi process. Response rates for Delphi rounds one, two, and three were 88% (n=9), 82% (n=73), and 100% (n=10), respectively. A final list of 10 defined endpoints was refined and developed, of which six secured approval by ≥70% of the group: cancer health related quality of life, days alive and out of hospital at 90 days, time to tumour progression, disease-free survival, cancer-specific survival, and overall survival (and 5-yr overall survival).

CONCLUSION

Standardised endpoints in clinical outcomes studies will support benchmarking and pooling (meta-analysis) of trials. It is therefore recommended that one or more of these consensus-derived endpoints should be considered for inclusion in clinical trials evaluating a causal effect of anaesthesia-analgesia technique on oncological outcomes.

Prevalence of obesity in Malta

Background

Obesity is a global epidemic with the Mediterranean island of Malta being no exception. The World Health Organization (WHO) has identified Malta as one of the European countries with the highest obesity prevalence.

Method

A cross‐sectional study was conducted (2014–2016) under the auspices of the University of Malta. The prevalence of overweight‐obesity in Malta was calculated and then age stratified for comparisons with previous studies.

Results

The study identified 69.75% (95% CI: 68.32–71.18) of the Maltese population to be either overweight or obese. The men overweight/obese prevalence (76.28% 95% CI: 74.41–78.14) was statistically higher than that for women (63.06% 95% CI: 60.92–65.20) (p = 0.0001). Age stratification revealed that both genders had the highest overweight prevalence rates between 55 and 64 years (Men = 23.25% 95% CI: 20.43–26.33; Women = 24.68% 95% CI: 21.44–28.22). Men obesity prevalence rates were highest in the 35 to 44 years group (22.52% 95% CI: 19.65–25.68) while for women it was highest in the 55 to 64 years group (28.90%, 95% CI: 25.44–30.63).

Conclusion

Over a 35‐year period, an overall decrease in the normal and overweight BMI categories occurred with an increase in the prevalence of obesity. An exception was observed in the women, where the prevalence of normal BMI increased over this time period. Also, it appears that while the total population obesity prevalence increased (for 2016), a percentage of the women have shifted from an obese to an overweight status.

Hamstrings anterior cruciate ligament reconstruction with and without platelet rich fibrin matrix

PURPOSE

Anterior cruciate ligament (ACL) rupture is the most common complete ligamentous injury in the knee. Many studies explored ACL graft integration and maturation, but only a few assessed the application of platelet rich fibrin matrix (PRFM) as augmentation for ACL reconstruction. The main aim of this study was to test the PRFM augmentation in terms of graft-bone integration and knee stability. The secondary aim was to investigate patient-reported functional status.

METHODS

Prospective evaluation has been done in two consecutive series of patients who underwent ACL reconstruction with semitendinosus and gracilis (STG) grafts: 14 patients were operated with PRFM augmentation and 14 patients without PRFM augmentation. Objective clinical evaluation (Rolimeter) and MRI evaluation were performed at 1 year from surgery. Subjective evaluation (IKDC) was performed pre-operatively and at 6 months, 1 and 2 years from surgery.

RESULTS

A statistically significant difference was not detected between the two groups in terms of MRI and objective clinical evaluation, although PRFM-augmented patients showed a statistically significant higher clinical improvement.

CONCLUSIONS

The procedure described for PRFM augmentation in ACL STG reconstruction does not improve radiologic graft integration and knee stability after 1 year and should not be used by clinicians to this purpose. However, it may result in a short-term improvement of patient-reported knee function, and future research should focus on further developing PRP treatment to optimize ACL clinical outcome.

LEVEL OF EVIDENCE

III.

Understanding how women's groups improve maternal and newborn health in Makwanpur, Nepal: a qualitative study

Women's groups, working through participatory learning and action, can improve maternal and newborn survival. We describe how they stimulated change in rural Nepal and the factors influencing their effectiveness. We collected data from 19 women's group members, 2 group facilitators, 16 health volunteers, 2 community leaders, 21 local men, and 23 women not attending the women's groups, through semi-structured interviews, group interviews, focus group discussions and unstructured observation of groups. Participants took photographs of their locality for discussion in focus groups using photoelicitation methods. Framework analysis procedures were used, and data fed back to respondents. When group members were compared with 11 184 women who had recently delivered, we found that they were of similar socioeconomic status, despite the context of poverty, and caste inequalities. Four mechanisms explain the women's group impact on health outcomes: the groups learned about health, developed confidence, disseminated information in their communities, and built community capacity to take action. Women's groups enable the development of a broader understanding of health problems, and build community capacity to bring health and development benefit.

Mortality reporting in interventional radiology: experience of a pilot audit with the Scottish Audit of Surgical Mortality

AIM

To describe the initial pilot phase of the 2009 Scottish Audit of Surgical Mortality (SASM), which includes outcomes and difficulties that arose during any interventional radiology (IR) procedure performed on patients in this audit over an 18 month period.

MATERIALS AND METHODS

Approximately 40 consultant interventional radiologists from all units in Scotland elected to participate in the audit. Each response was then peer reviewed after anonymisation of the patient and institution. If a relevant ACON (area for consideration or area of concern) was generated, this was checked by one of the other reviewers before communication with the original reporting radiologist and colleagues. There was then a right of reply by the reporting unit before formal documentation was sent out.

RESULTS

Initial results were analysed after 18 months period, during which time 95 forms relating to deaths of surgical inpatients were sent to interventional radiologists identified as having been involved in an IR procedure at some time during the patient's admission. Seventy-one forms had been returned by July 2010, of which 46 had gone through the entire SASM process. From these, 10 ACONs were attributed. Anonymised case vignettes and reports from these were used as educational tools.

CONCLUSION

Involvement with SASM is a useful process. Significant safety issues and learning points were identified in the pilot. The majority of ACONs identified by the audit were in patients who had undergone percutaneous biliary interventions.

Continuous 30-day measurements utilizing the monkey metabolism pod

We have previously described a fibreglass pod system which makes possible quantitative physiological measurements to study the effects of weightlessness on 10-14-kg adult monkeys maintained in comfortable restraint under space flight conditions. Recent improvements in the system have allowed continuous measurements to be made of respiratory gas exchange, cardiovascular function, and mineral balance for periods of up to 30 days on pig-tailed monkeys. It has also been possible to operate two pods which share one set of instrumentation, thereby permitting simultaneous measurements to be made on two animals by commutating signal outputs from the pods. In principle, more than two pods could be operated in this fashion. The system is compatible with Spacelab design. Representative physiological data from ground tests of' the system are presented.

Metabolic responses of monkeys to increased gravitational fields

A depletion of body fat has been reported by several investigators for various species of homoiotherms exposed to chronic acceleration. Generally the effect is proportional to field strength, and over the size range examined (0.25-5 kg) it becomes more severe in larger animals. There is some evidence that this may be the result of increased secretion of a pituitary hormone, the fat mobilizing substance (FMS). An exception to the defatting effect of chronic acceleration was observed in mature pig-tailed monkeys (Macaca nemestrina)--although they exhibited other changes generally found in homoiotherms exposed to hyperdynamic environments. It is considered that this unusual primate response to chronic acceleration may result from a different geometry of the central nervous system, and its effect upon gravity load distribution in the lower part of the brain.

Body composition changes in men and women after 2-3 weeks of bed rest

Several parameters of body composition were measured in eight men before and after 14 days of continuous recumbency, and in eight women before and after 17 days of recumbency. The parameters measured included body weight, body water, body potassium, plasma volume, and plasma protein concentrations. From these, values were derived for body fat content, lean body mass, body cell mass, and circulating plasma proteins. In general, the men and women responded similarly to continuous recumbency. Characteristically, there was significant reduction of plasma volume and body potassium in both groups. The women showed a significant reduction in circulating plasma protein, entirely in the albumin fraction; a similar change was observed in the men. The women, but not the men, showed a significant increase in circulating fibrinogen. Both men and women lost body cell mass, while body fat content remained the same or tended to increase slightly. It is expected that similar changes would occur in weightlessness. It is further concluded that women should tolerate the weightlessness of space flight physiologically as well as men.

Effect of 14 days of bed rest on urine metabolite excretion and plasma enzyme levels

After one week of ambulatory baseline measurement, a group of eight men 19-26 years of age remained continuously recumbent for 14 days. Studies were continued for one week following the prolonged recumbency. Urine excretion rates for a number of constituents were determined 2 days before bed rest, on day 14 of bed rest, and day 6 after bed rest. Blood plasma samples were also obtained at these times, and analyzed for several enzymes. On day 14 of bed rest significant increases were observed in urine excretion of total osmotically active substances, magnesium, calcium, phosphate, creatinine, hydroxyproline, and 17-OH corticosteroids. A decrease occurred in urinary glucose excretion. Plasma levels of alkaline phosphatase and LDH-3 were depressed, while plasma GPT was elevated. Many of these changes persisted on day 6 after bed rest, and are interpreted as concomitants of the disuse atrophy of the musculoskeletal system that characterizes prolonged bed rest and weightlessness.

Muscularity as a function of species, sex and age in small mammals

The size of individual skeletal muscles in mammals is well known to change with the degree of mechanical loading imposed on the muscle. Less clear has been the effect of changes in loading of the whole organism on size of the total skeletal musculature. Pitts and coworkers have provided valuable insights by dissection and weighing of the skeletal musculature of animals subjected to various chronic centrifugation, exercise and dietary regimens, and their recent findings are reported at this meeting. However, questions remain. Independently, our laboratory several years ago embarked on a systematic definition of body composition and energy metabolism changes as a function of sex and age in 5 species of small laboratory mammals, the mouse, hamster, rat, guinea pig and rabbit. Six animals of each sex were examined in 8 age cohorts ranging from 1 to 24 months for each of the 5 species.

Use of standardized patients to evaluate the physicians in residence program: a substance abuse training approach

The purpose of this study was to evaluate the efficacy of the Physician in Residence (PIR) program at the Hazelden Residential Program of New York City as a substance abuse training approach using standardized patients (SP) and self-report ratings. Using an objective rating scale, two experienced drug counselors evaluated four videotaped interviews carried out by housestaff pre- and post-enrollment in the PIR program. In addition, housestaff completed self-report ratings regarding their knowledge, attitudes, and skills of substance abuse. Of the 23 housestaff who completed both pre- and post-PIR program videotape sessions, significant improvements were noted in both observer and self-reported ratings. Overall, self-report ratings showed a greater percent improvement than the counselor ratings. The PIR program may be an efficacious approach to teach substance abuse clinical skills to housestaff.

Factors affecting the efficiency of collection of CD34-positive peripheral blood cells by a blood cell separator

BACKGROUND

The yield of CD34-positive cells obtained from an apheresis procedure is determined, in part, by the efficiency of collection. Optimization of the efficiency of CD34-positive peripheral blood cell collection requires identification of predictive factors.

STUDY DESIGN AND METHODS

Demographic, stem cell collection, mobilization, and disease-related measures from autologous and allogeneic donors undergoing 252 progenitor cell apheresis procedures were retrospectively reviewed. Statistical relationships between CD34 collection efficiency and the various measures were determined by correlation and multiple linear regression analysis.

RESULTS

CD34 collection efficiency inversely correlated with the peripheral white cell count, hematocrit, and serum albumin concentration (R2 = 0.29). White cell count was the single best predictor of CD34 efficiency (R2 = 0.19). Donor groups with cytopenias (patients vs. normal donors; increased cycles of prior chemotherapy; bone marrow involvement; chemotherapy plus growth factor mobilization) had higher collection efficiencies. Only 29 percent of the variability in the data could be attributed to white cell count, hematocrit, and albumin concentration. The majority of the remaining variability was due to unexplained differences between donors.

CONCLUSION

CD34 collection efficiencies show considerable variation. Higher peripheral white cell counts, hematocrits, and/or albumin concentrations result in decreased CD34 collection efficiency, but most of the variability in the data is not accounted for by these three factors.

Selectively withholding treatment from newborn babies

Whether to withhold life-prolonging treatment from a severely handicapped newborn baby is a topical moral dilemma. Some recent prominent court cases in the UK highlight the ethical issues that have to be faced when considering such a decision.

Moral principles in withdrawing basic life support from patients in the persistent vegetative state

Patients in a state of persistent vegetation or 'cognitive death' are an emotional drain on their family, and a financial drain on a society with limited resources. In this article, society's responsibility towards these patients and the moral and ethical issues involved in the withdrawal of fluid and nutrition are discussed.

The tarsal and calcaneal tunnel syndromes

This paper concerns 22 cases of compression of the posterior tibial nerve and its branches in the tarsal and calcaneal tunnels, all of which were treated by surgical decompression. The evaluation of both the operative findings and the results after a follow-up period ranging from 4 months to 2 years confirms the validity of neurolysis and emphasizes the role of the abductor hallucis muscle in the compression of the terminal branches of the posterior tibial nerve in the calcaneal tunnel.

Moral principles in withdrawing advanced life support

Decisions regarding withdrawal of life support are more frequently required as our technological capabilities increase. Doctors have to recognize that in certain cases maximal use of these capabilities may be incompatible with the patient's best interests. An ethical framework may help guide doctors through these dilemmas.

A comparison between conservative treatment and operative treatment (capsulosyndesmorrhaphy) in severe acute capsuloligamentous lateral lesions of the ankle joint

The authors report 31 cases of acute severe capsuloligamentous lateral lesions of the ankle joint, 12 of which were treated surgically and 18 with a below knee plaster cast. An evaluation of the results at an average 20 months follow-up showed the superiority of the conservative method.

Predicting deaths among intensive care unit patients

Daily APACHE II assessments to reflect the dynamic pathophysiologic processes affecting ICU patients were carried out prospectively on 212 adult ICU admissions for the purpose of predicting hospital outcome. Trend analysis of daily APACHE II scores was used to develop the first set of criteria for predicting deaths among the ICU patients. The analysis took into account the absolute value of APACHE II score of each day and the rate of change relative to that of the previous day. One hundred consecutive adult ICU admissions were used to determine the criteria that were tested on the following 112 consecutive adult ICU admissions. Daily APACHE II scores identified correctly 16 of the 34 patients who died. A second set of criteria was next derived by raising the values of the original limits in order to build-in greater margins of safety without too great a loss of sensitivity. The predictive power of daily APACHE II scores using the second set of criteria was superior to that of a single APACHE II score by a factor of 4. Predictions were not used to influence clinical decision-making during this study.

The RNA moiety of ribonuclease P is the catalytic subunit of the enzyme

The RNA moieties of ribonuclease P purified from both E. coli (M1 RNA) and B. subtilis (P-RNA) can cleave tRNA precursor molecules in buffers containing either 60 mM Mg2+ or 10 mM Mg2+ plus 1 mM spermidine. The RNA acts as a true catalyst under these conditions whereas the protein moieties of the enzymes alone show no catalytic activity. However, in buffers containing 5-10 mM Mg2+ (in the absence of spermidine) both kinds of subunits are required for enzymatic activity, as shown previously. In the presence of low concentrations of Mg2+, in vitro, the RNA and protein subunits from one species can complement subunits from the other species in reconstitution experiments. When the precursor to E. coli 4.5S RNA is used as a substrate, only the enzyme complexes formed with M1 RNA from E. coli and the protein moieties from either bacterial species are active.