Telemedicine acceptance by older adults in Hong Kong during a hypothetical severe outbreak and after the COVID-19 pandemic: a cross-sectional cohort survey

INTRODUCTION

Telemedicine services worldwide have experienced unprecedented growth since the early days of the coronavirus disease 2019 (COVID-19) pandemic. Multiple studies have shown that telemedicine is an effective alternative to conventional in-person patient care. This study explored the public perception of telemedicine in Hong Kong, specifically among older adults who are most vulnerable to COVID-19.

METHODS

Medical students from The Chinese University of Hong Kong conducted in-person surveys of older adults aged ≥60 years. Each survey collected socio-demographic information, medical history, and concerns regarding telemedicine use. Univariate and multivariate logistic regression analyses were conducted to identify statistically significant associations. The primary outcomes were acceptance of telemedicine use during a hypothetical severe outbreak and after the COVID-19 pandemic.

RESULTS

There were 109 survey respondents. Multivariate logistic regression analyses revealed that the expectation of government subsidies for telemedicine services was the strongest common driver and the only positive independent predictor of telemedicine use during a hypothetical severe outbreak (P=0.016) and after the COVID-19 pandemic (P=0.003). No negative independent predictors of telemedicine use during a hypothetical severe outbreak were identified. Negative independent predictors of telemedicine use after the COVID-19 pandemic included older age and residence in the New Territories (both P=0.001).

CONCLUSION

Government support, such as telemedicine-specific subsidies, will be important for efforts to promote telemedicine use in Hong Kong during future severe outbreaks and after the COVID-19 pandemic. Robust dissemination of information regarding the advantages and disadvantages of telemedicine for the public, especially older adults, is needed.

The clinical significance of osteopontin on the cardiovascular outcomes in patients with stable coronary artery disease

BACKGROUND

Osteopontin (OPN) is a noncollagenous matricellular protein which is mainly present in bone matrix. A high OPN level has been associated with heart failure and acute coronary syndrome, however data on patients with chronic coronary syndrome (CCS) are lacking. The present study aimed to evaluate the association between OPN and the prognosis of Taiwanese patients with CCS.

METHODS

We enrolled participants from the Biosignature Registry, a nationwide prospective cohort study conducted at nine different medical centers throughout Taiwan. The inclusion criteria were participants who had received successful percutaneous coronary intervention at least once previously, and stable under medical therapy for at least 1 month before enrollment. They were followed for at least 72 months. Logistic regression and Cox proportional hazard model were used to investigate the association between OPN and clinical outcomes. The outcomes of this study were the first occurrence of hard cardiovascular events and composite cardiovascular outcomes including cardiovascular mortality, revascularization, hospitalization for acute myocardial infarction (AMI) or heart failure.

RESULTS

A total of 666 patients with both hs-CRP and osteopontin measurements were enrolled and followed for 72 months. OPN was correlated positively with AMI-related hospitalization, where the highest tertile (Tertile 3) of baseline OPN had the highest risk of AMI-related hospitalization, which remained significant after multivariate adjustments (HR 3.20, p = 0.017). In contrast, combining OPN and hs-CRP did not improve the prediction of CV outcomes.

CONCLUSION

OPN may be a potentially valuable biomarker in predicting CV outcomes. During 6 years of follow-up period, an OPN level >4810 pg/ml was associated with a significantly higher incidence of AMI-related hospitalization in CCS patients who received successful PCI before the enrollment.

Low Adherence to Immunosuppressants Is Associated With Symptom Experience Among Kidney Transplant Recipients

PURPOSE

The purpose of this study was to investigate the relationship between immunosuppressant-related symptom experience (SE) and adherence to immunosuppressant regimens among kidney transplant (KT) recipients.

METHODS

A total of 239 KT recipients on an immunosuppressant regimen who were followed up after transplantation participated in this study. Data was collected through a self-reported questionnaire survey (medication adherence, SE, and quality of life) and medical record review.

RESULTS

Low adherence in the immunosuppressant group was associated with longer time since KT, less comorbidity (<3), and a higher rehospitalization rate. Low adherence among KT recipients showed significantly greater overall symptom occurrence (P = .001) and symptom distress (P = .002) levels than patients with high or medium adherence after adjusting for a number of covariates. The most common symptom both in terms of occurrence (96.4%) and distress (91.1%) among poorly adherent KT recipients was tiredness.

CONCLUSION

Low adherence to an immunosuppressant regimen was significantly associated with high SE among KT recipients. Strategies to decrease immunosuppressant-related SE are needed to improve adherence to immunosuppressants.

Innominate Artery Cannulation for Aortic Surgery

When disease involving the ascending aorta or aortic arch precludes ascending aortic cannulation, axillary artery cannulation is used for cardiopulmonary bypass. An additional incision and the relatively small caliber of the axillary artery are the drawbacks of this approach. Innominate artery cannulation using the same sternotomy wound is a simple and effective alternative.

Needs assessment for master of nursing programmes among Bangladesh nurses

AIM

This study aimed to assess the intent to enrol in a master of nursing programme among Bangladesh nurses, identify preferred programme options and measure the association among intent to enrol in the programme, clinical competency and job satisfaction.

BACKGROUND

Personal and professional aspects of potential students pursuing graduate education are beneficial in devising educational strategies. However, considering the pressing needs for higher nursing education, there are no masters of nursing programmes in Bangladesh.

METHODS

This study used a descriptive correlational design. Nurses working in Bangladesh public sector were recruited to participate in a self-administered survey (n = 260). The questionnaire consisted of perception of job satisfaction, clinical competency and the need for educational options, including the intent to enrol in a master of nursing programme, preferred specialty area, curriculum content and career goals after graduation. Data were analysed using descriptive statistics and point-biserial correlation.

RESULTS

Ninety per cent of the respondents reported that they intended to enrol in a master of nursing programme. Intention was significantly correlated with clinical competency but not with job satisfaction. The most preferred specialty areas were nursing management and education. Half of the respondents responded that teaching at nursing schools was a career goal after graduation.

DISCUSSION

The results of the needs assessment for the programme reflected the unique interest and priorities of the current status of Bangladesh.

CONCLUSIONS

The results indicate a strong motivation to enrol in a master of nursing programme, confidence in clinical competence and high demand for programme in nursing management and education. These findings should be considered to design the programme in order to meet the interest of Bangladesh nurses.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Educational needs assessments should take precedence to ensure the best possible educational outcome and to produce competent nurses who will contribute in achieving the Millennium Development Goals of Bangladesh.

Intraoperative Measurement of Fractional Flow Reserve in Off-Pump Coronary Artery Bypass: A Pilot Study

BACKGROUNDS

Fractional flow reserve of myocardium (FFRmyo) is a functional study of significant coronary artery stenosis, defined as the ratio of the pressure distal to the stenosis (poststenosis) divided by the pressure of aortic root (prestenosis). Instead of cath laboratory, we could measure it in operating room for off-pump coronary artery bypass (OPCAB) surgery and here shared our methods in the pilot study.

METHODS AND RESULTS

We used needles, catheters, and pressure tracing but without guidewires or fluoroscopy to measure FFRmyo during OPCAB. In February 2010, we conducted the pilot study and collected 32 anastomosis data from 10 patients. Without revising the anastomosis plans based on coronary angiographies, 24 FFRmyo of the 32 anastomoses (75%) were less than 0.75, which represented significant functional stenosis. The FFRmyo measurements did not lead to any adverse events.

CONCLUSION

The measurement of fractional flow reserve in OPCAB is safe and feasible. It can serve as a functional assessment of coronary artery stenosis in adjuvant to conventional coronary angiography.

Loss of speech after living-related donor liver transplantation: detection of the lesion by diffusion tensor image

INTRODUCTION

Loss of speech after living-related liver transplantation is uncommon. Either immunosuppressive agents, related sequelae, or a neurological event may cause it.

CASE REPORT

A 46-year-old man developed dysarthria and dysphagia on the 10th day after living-related donor liver transplantation for alcoholic cirrhosis with Child-Pugh class C. Brain magnetic resonance images and electroencephalograms could not detect any lesion, but the diffusion tensor image showed a subacute lacunar infarction at right midbrain. The patient's speech improved 1 month after rehabilitation.

CONCLUSIONS

Some unexpected neurological events, such as loss of speech, may occur after liver transplantation. The differential diagnosis becomes very important before active treatment. Magnetic resonance imaging supplemented with diffusion tensor imaging is an effective imaging study in establishing the diagnosis.

Right mini-parasternotomy may be a good minimally invasive alternative to full sternotomy for cardiac valve operations-a propensity-adjusted analysis

AIM

Limited realworld data existed for miniparasternotomy approach with good sample size in Asian cohorts and most previous studies were eclipsed by case heterogeneity. The goal of this study was to compare safety and quality outcomes of cardiac noncoronary valve operations by miniparasternotomy and full sternotomy approaches on riskadjusted basis.

METHODS

From our hospital database, we retrieved the cases of non-coronary valve operations from 1 January 2005 to 31 December 2012, including re-do, emergent, and combined procedures. Estimated EuroScore-II and propensity score for choosing mini-parasternotomy were adjusted for in the regression models on hospital mortality, complications (pneumonia, stroke, sepsis, etc.), and quality parameters (length of stay, ICU time, ventilator time, etc.). Non-complicated cases, defined as survival to discharge, ventilator use not over one week, and intensive care unit stay not over two weeks, were used for quality parameters.

RESULTS

There were 283 miniparasternotomy and 177 full sternotomy cases. EuroScore-II differed significantly (medians 2.1 vs. 4.7, p<0.001). Propensity scores for choosing miniparasternotomy were higher with lower EuroScore-II (OR=0.91 per 1%, p<0.001), aortic regurgitation (OR=2.3, p=0.005), and aortic non-mitral valve disease (OR=3.9, p<0.001). Adjusted for propensity score and EuroScore-II, mini-parasternotomy group had less pneumonia (OR=0.32, p=0.043), less sepsis (OR=0.31, p=0.045), and shorter non-complicated length of stay (coefficient=7.2 (day), p<0.001) than full sternotomy group, whereas Kaplan-Meier survival, non-complicated ICU time, non-complicated ventilator time, and 30-day mortality did not differ significantly.

CONCLUSION

The propensity-adjusted analysis demonstrated encouraging safety and quality outcomes for mini-parasternotomy valve operation in carefully selected patients.

Laparoscopic caudate hepatectomy for cancer--an innovative approach to the no-man's land

BACKGROUND

Caudate hepatectomy remains a surgical challenge in spite of recent advances in laparoscopic technique. Hepatic tumor in the caudate lobe is usually deeply located in the center of the liver and close to the vena cava and hepatic hilum. Thus, lesion in this region was considered as a contraindication of laparoscopic hepatectomy. Only sporadic reports could be found in the literature. The aim of this study is to review the safety and feasibility of laparoscopic hepatectomy for lesions in the caudate lobe.

METHODS

Nine consecutive patients with caudate hepatic tumor received laparoscopic caudate hepatectomy in our institute from February 2006 to July 2010. One patient with hepatic adenoma was excluded from the analysis. Demographic data, intraoperative parameters, and postoperative outcomes of the remaining eight patients were assessed.

RESULTS

All procedure for these eight patients with caudate hepatic tumors (size 0.9-4.5 cm) were completed with totally laparoscopic technique except one in which additional left hepatectomy was also done. The average operative time was 254 min (range 210-345 min) and estimated blood loss was 202 ml (range 10-1,000 ml), and average length of postoperative hospital stay was 6.9 days (range 4-11 days). There was no perioperative complications and patient mortality in this series.

CONCLUSIONS

Our experience demonstrated that laparoscopic hepatectomy is a safe and feasible procedure for caudate hepatic tumors in selected patients.

Cardioplegia delivery by transcutaneous pigtail catheter in minimally invasive mitral valve operations

For cardioplegia delivery and removing air from the aorta in minimally invasive mitral valve operations, we would like to propose a cost-effective pigtail method. The 8F pigtail punctures the aorta, delivers cardioplegia, and stays in place for removing air from the aorta. We then slide its tip out of the aorta as an accessory drain. With more than 100 successes, we are using it in every case and would like to share it with peer surgeons.

Bloodstream infection in heart transplant recipients: 12-year experience at a university hospital in Taiwan

OBJECTIVE

Bloodstream infection (BSI) is a well-recognized problem and it affects 10-50% of solid organ transplant recipients. The purpose of this study was to assess the incidence and prognosis of BSI in heart transplant recipients at our hospital.

METHODS

The study is a retrospective chart review.

RESULTS

We diagnosed 101 episodes of BSI in 73 out of 306 heart transplant patients (24%) during the 12-year study period. BSI occurred at a median of 191 days (range 1-3376) after transplant and 50% occurred within 6 months after transplant. Most BSI episodes were nosocomial (73%), especially those occurring within the first month (94%). As far as pathogen was concerned, Gram-negative bacteria predominated (57%), followed by Gram-positive bacteria (34%), fungus (5%), anaerobics (2%), and cryptococcus (2%). Overall 30-day mortality rate was 30%. Death occurred in 36% (13/36) of the patients with early-onset BSI, 14% (2/14) of the patients with BSI in months 2-6, and 29% (15/51) of the patients with late-onset BSI. Mortality rate was over 50% in those patients with Pseudomonal infection, fungal infection, cryptococcal infection of central nervous system, lung infection, and severe sepsis. Compared to Western series, there was a high incidence of infections caused by Enterobacter species and Acinetobacter baumannii.

CONCLUSIONS

There was a high incidence of BSI after heart transplantation in Taiwan, especially infections caused by Enterobacter species and A. baumannii. Mortality was high in patients with infection caused by Pseudomonas, Candida, and Cryptococcus and in patients with severe sepsis.

Recurrent cervical carcinoma presenting as a primary aortoduodenal fistula

Aortoduodenal fistula is a rare cause of gastrointestinal (GI) bleeding, and carries high morbidity and mortality even in modern practice. Cervical carcinoma is a major health threat among adult women, and its recurrence is not uncommon. We herein present a case of primary aortoduodenal fistula because of recurrent cervical carcinoma. Our case demonstrated that diagnosis of primary aortoenteric fistula requires a high index of suspicion and a combination of diagnostic modalities to establish the diagnosis. Prompt diagnosis and rapid treatment are critical in reducing mortality and morbidity. Although rare, metastatic carcinoma can lead to aortoenteric fistula.

Tetrandrine ameliorated reperfusion injury of small bowel transplantation

PURPOSE

In small bowel transplantation, the bowel graft is susceptible to reperfusion injury. This study investigated the effects of tetrandrine, a bisbenzylisoquinoline alkaloid, on the development of intestinal reperfusion injury in small bowel transplantation in pigs.

MATERIALS AND METHODS

Pigs underwent small bowel transplantation and were treated with tetrandrine or a vehicle. Blood and small bowel specimens were harvested at 1, 3, and 24 hours after reperfusion. Histopathologic analysis of the small bowel was assessed for tissue damage. Serum levels of tumor necrosis factor-alpha, interleukin-1beta (IL-1beta), and IL-6 were measured by enzyme-linked immunosorbent assay. Reverse-transcriptase polymerase chain reaction analysis was performed to analyze the expression of proinflammatory cytokines, and immunohistochemical analysis was used to study the expression of intercellular adhesion molecule-1 (ICAM-1) in the small bowel. Myeloperoxidase staining detected neutrophil infiltration in the small bowel and the number of myeloperoxidase positively stained cells was counted.

RESULTS

Pigs receiving small bowel transplantation had elevated serum proinflammatory cytokine levels. The transplanted small bowel showed mucosal damage, increased expression of proinflammatory cytokines and ICAM-1, and prominent neutrophil infiltration. Tetrandrine administration reduced mucosal damage, serum and tissue proinflammatory cytokine levels, ICAM-1 expression, and neutrophil accumulation in the transplanted small bowel.

CONCLUSIONS

Tetrandrine reduced the reperfusion injury in porcine intestinal transplantation during the first 24 hours after the procedure.

Dimethylthiourea normalizes velocity-dependent, but not force-dependent, index of ventricular performance in diabetic rats: role of myosin heavy chain isozyme

Hydroxyl radicals and hydrogen peroxide are involved in the pathogenesis of systolic dysfunction in diabetic rats, but the precise mechanisms and the effect of antioxidant therapy in diabetic subjects have not been elucidated. We aimed to evaluate the effects of dimethylthiourea (DMTU), a potent hydroxyl radical scavenger, on both force-dependent and velocity-dependent indexes of cardiac contractility in streptozotocin (STZ)-induced early and chronic diabetic rats. Seventy-two hours and 8 wk after STZ (55 mg/kg) injection, diabetic rats were randomized to either DMTU (50 mg x kg(-1) x day(-1) ip) or vehicle treatment for 6 and 12 wk, respectively. All rats were then subjected to invasive hemodynamic studies. Maximal systolic elastance (E(max)) and maximum theoretical flow (Q(max)) were assessed by curve-fitting techniques in terms of the elastance-resistance model. Both normalized E(max) (E(maxn)) and afterload-adjusted Q(max) (Q(maxad)) were depressed in diabetic rats, concomitant with altered myosin heavy chain (MHC) isoform composition and its upstream regulators, such as myocyte enhancer factor-2 (MEF-2) and heart autonomic nervous system and neural crest derivatives (HAND). In chronic diabetic rats, DMTU markedly attenuated the impairment in Q(maxad) and normalized the expression of MEF-2 and eHAND and MHC isoform composition but exerted an insignificant benefit on E(maxn). Regarding preventive treatment, DMTU significantly ameliorated both E(maxn) and Q(maxad) in early diabetic rats. In conclusion, our study shows that DMTU has disparate effects on Q(maxad) and E(maxn) in chronic diabetic rats. The advantage of DMTU in chronic diabetic rats might involve normalization of MEF-2 and eHAND, as well as reversal of MHC isoform switch.

Impact of an audit program and other factors on door-to-balloon times in acute ST-elevation myocardial infarction patients destined for primary coronary intervention

OBJECTIVES

This before-after study investigated the association between an audit program and door-to-balloon times in patients with acute ST-elevation myocardial infarction (STEMI) and explored other factors associated with the door-to-balloon time.

METHODS

An audit program that collected time data for essential time intervals in acute STEMI was developed with data feedback to both the Department of Emergency Medicine and the Department of Cardiology. The door-to-balloon times for 76 consecutive acute STEMI patients were collected from February 16, 2007, through October 31, 2007, after the implementation of the audit program, as the intervention group. The control group was defined by 104 consecutive acute STEMI patients presenting from April 1, 2006, through February 15, 2007, before the audit was applied. A multivariate linear regression model was used for analysis of factors associated with the door-to-balloon time.

RESULTS

The geometric mean 95% CI of the door-to-balloon time decreased from 164.9 (150.3, 180.9) minutes to 141.9 (127.4, 158.2) minutes (p = 0.039) in the intervention phase. The median door-to-balloon time was 147.5 minutes in the control group and 136.0 minutes in the intervention group (p = 0.09). In the multivariate regression model, the audit program was associated with a shortening of the door-to-balloon time by 35.5 minutes (160.4 minutes vs. 195.9 minutes, p = 0.004); female gender was associated with a mean delay of 58.4 minutes (208.9 minutes vs. 150.5 minutes; p = 0.001); posterolateral wall infarction was associated with a mean delay of 70.5 minutes compared to anterior wall infarction (215.4 minutes vs. 144.9 minutes; p = 0.037) and a mean delay of 69.5 minutes compared to inferior wall infarction (215.4 minutes vs. 145.9 minutes; p = 0.044). The use of a glycoprotein IIb/IIIa inhibitor was associated with a 46.1 minutes mean shortening of door-to-balloon time (155.7 minutes vs. 201.8 minutes; p < 0.001).

CONCLUSIONS

The implementation of an audit program was associated with a significant reduction in door-to-balloon times among patients with acute STEMI. In addition, female patients, posterolateral wall infarction territory, and nonuse of glycoprotein IIb/IIIa inhibitor were associated with longer door-to-balloon times.

Surgical treatment of left main coronary artery aneurysm: a case report

Left main (LM) coronary artery aneurysm is rare and usually found incidentally during coronary angiography. Except for rare Kawasaki disease, iatrogenic and mycotic aneurysms, atherosclerosis is the primary cause of coronary aneurysm. In most clinical scenarios, coronary artery disease is accompanied with LM coronary aneurysm. Although coronary artery aneurysm does not confer added risk in patients with coexisting obstructive coronary artery disease, LM coronary aneurysm itself remains a significant clinical concern. Thrombosis and distal embolization are the most likely reasons to cause morbidities. Aggressive surgical treatment should be considered. Here, we report a 65-year-old man presenting with effort angina. LM coronary aneurysm was noted in coronary angiogram and images including computed tomography, transesophageal echocardiography and operative photography were presented.

Emergency redo mitral valve replacement in a pregnant woman at third trimester: case report and literature review

Pregnancy carries significant physiological changes that demand more cardiac output, so structural cardiac disease can cause life-threatening complications. A woman had rheumatic mitral stenosis and underwent mitral valve replacement (MVR) with bioprosthesis 8 years prior to admission. She presented with dyspnea and leg edema at 30 weeks of gestation. Severe mitral stenosis caused by xenograft failure was noted on echocardiography. Management was conservative until a sudden onset of hemodynamic compromise requiring emergency redo MVR under normothermic cardiopulmonary bypass with intra-aortic balloon pump. Monitoring of fetal heartbeat and uterine contractions showed no significant abnormalities and the woman gave birth to a full-term baby by Cesarean section with postoperative warfarin therapy.

Total laparoscopic repair for abdominal aortic aneurysm

Surgical resection and grafting have long been the standard treatment for abdominal aortic aneurysm and provide an excellent long-term outcome. However, there is tremendous impact on patients due to the surgical invasiveness. Endovascular aortic repair using stent graft was introduced in 1991. After refinement of the techniques and technology, endovascular aortic repair was approved by most health authorities and is associated with less periprocedural morbidities. In between these two extremes, some surgeons endeavored to create an alternative and perform less invasive surgeries. Hand-assisted laparoscopic aortic surgery and laparoscopic-assisted aortic surgery were introduced in 1996. In 2001, total laparoscopic abdominal aortic aneurysm resection with tube graft interposition was first performed in Canada. Till now, only a few vascular units in North America and Europe perform these delicate techniques. We report our first case of total laparoscopic abdominal aortic aneurysm repair. Laparoscopic aortic surgery provides better visualization of the aneurysm neck, less bowel manipulation and avoidance of hypothermia. The minimal invasiveness could translate to better perioperative outcome. To our knowledge, this is also the first case report in Asia. The detailed techniques are described.

Brachial artery flow-mediated vasodilation in patients with cardiac syndrome X

Cardiac syndrome X (CSX) differs from coronary artery disease (CAD) and is characterized by angina, positive stress test, and patent coronary arteries. The probable mechanism is a microvascular disorder associated with endothelial dysfunction. In this study, brachial artery flow-mediated vasodilation was used as well as the endothelin-1 assay to assess endothelial function in patients with cardiac syndrome X (CSX), coronary artery disease (CAD), and healthy controls. All subjects underwent a 2-step brachial artery flow-related vasodilatation test. Serum endothelin-1, one of the most potent constricting factors, was measured for all participants. Patients with CSX had a lower brachial artery dilation ratio than controls but higher than that of CAD patients. Control subjects and CSX patients had higher endothelin-1 levels than CAD patients. CSX patients were found to have worse endothelial function than healthy volunteers, but patients with CAD had even worse endothelium function than CSX patients.

Temporal changes in cardiac force- and flow-generation capacity, loading conditions, and mechanical efficiency in streptozotocin-induced diabetic rats

Diabetes mellitus may result in impaired cardiac contractility, but the underlying mechanisms remain unclear. We aimed to investigate the temporal alterations in cardiac force- and flow-generation capacity and loading conditions as well as mechanical efficiency in the evolution of systolic dysfunction in streptozotocin (STZ)-induced diabetic rats. Adult male Wistar rats were randomized into control and STZ-induced diabetic groups. Invasive hemodynamic studies were done at 8, 16, and 22 wk post-STZ injection. Maximal systolic elastance (Emax) and maximum theoretical flow (Qmax) were assessed by curve-fitting techniques, and ventriculoarterial coupling and mechanical efficiency were assessed by a single-beat estimation technique. In contrast to early occurring and persistently depressed Emax, Qmax progressively increased with time but was decreased at 22 wk post-STZ injection, which temporally correlated with the changes in cardiac output. The favorable loading conditions enhanced stroke volume and Qmax, whereas ventriculoarterial uncoupling attenuated the cardiac mechanical efficiency in diabetic animals. The changes in Emax and Qmax are discordant during the progression of contractile dysfunction in the diabetic heart. In conclusion, our study showed that depressed Qmax and cardiac mechanical efficiency, occurring preceding overt systolic heart failure, are two major determinants of deteriorating cardiac performance in diabetic rats.

The thicker the skin fold, the less hematoma development: a novel parameter other than body mass index associated with transradial vascular complication

It was reported recently that body mass index (BMI) is a prognostic factor of vascular complications after radial puncture, and that extremely thin patients are at higher risk than obese subjects. However, the underlining mechanism of this phenomenon has rarely been studied. Therefore, we conducted a survey measuring a novel parameter, the skin fold thickness, and other potential risk factors in our patients developing postprocedure hematoma. In 1176 consecutive patients undergoing percutaneous radial catheterization, 18 (1.53%) developed hematoma afterward. When a patient with hematoma had been identified, the next patient having no hematoma after radial puncture was enrolled into the control group, which thus turned out to have 18 patients. In addition, we also compared the BMI, skin fold thickness, and other potential risk factors, including heparin dosage and antiplatelet medication, between these 2 groups. We found hematoma patients to be older (69.5 +/- 10.3 years vs 61.50 +/- 11.7 years, P = .037), to have more cases of coronary intervention (10/18 vs 4/18, P = .04), to have lower BMI (23.63 +/- 4.03 vs 27.25 +/- 4.38, P = .014), and to have thinner skin folds of forearm (5.94 +/- 4.56 vs 9.27 +/- 3.06 mm, P = .015), deltoid area (14.61 +/- 9.00 vs 19.73 +/- 7.15 mm, P = .042), and waist (21.94 +/- 9.90 vs 29.00 +/- 8.46 mm, P = .028) than the nonhematoma group. On the contrary, no statistical difference in heparin dosage or other factors was noted between the 2 groups. We conclude that the vascular complication rate after radial catheterization is higher in elderly patients with lower BMI, body weight, or thinner skin folds.

Incidence, risk factors, and prognosis of postoperative hyperbilirubinemia after heart transplantation

OBJECTIVE

The clinical significance of postoperative hyperbilirubinemia after heart transplantation has not been reported. Here, we sought to evaluate the incidence, risk factors, and prognosis of postoperative hyperbilirubinemia after heart transplantation.

METHODS

Between 1987 and 2005, 256 consecutive patients undergoing heart transplantation were studied prospectively. Postoperative hyperbilirubinemia was defined as occurrence of a serum total bilirubin concentration of more than 3mg/dl in any measurement during the postoperative period. Logistic regression was done to identify possible risk factors for postoperative hyperbilirubinemia and hospital mortality.

RESULTS

Overall incidence of postoperative hyperbilirubinemia was 57%. Among all patients, there were 35 hospital deaths (14%). In patients with postoperative hyperbilirubinemia, the mean onset time was 2.4+/-4.4 days after transplantation and the mean peak serum total bilirubin was 10.1+/-10.4 mg/dl. Development of postoperative hyperbilirubinemia was associated with a higher mortality (21% vs 5%, P<0.001 by Fisher's exact test). The onset time of postoperative hyperbilirubinemia, the peak serum total bilirubin level, and the time at which the peak bilirubin level was reached were associated with hospital mortality. Old donor age, valvular heart disease, high right atrial pressure, use of mechanical ventilation before transplant, and ascites at transplant were the significant risk factors for postoperative hyperbilirubinemia.

CONCLUSIONS

Postoperative hyperbilirubinemia is common in patients undergoing heart transplantation and is associated with high hospital mortality. Patients with valvular heart disease, high preoperative right atrial pressure, and ascites at transplant, who then receive an old donor heart, are at greater risk for development of postoperative hyperbilirubinemia.

Percutaneous cardioplegia delivery using the miniport in minimally invasive mitral valve surgery

Minimally invasive cardiac surgery involves limited exposure of cardiac structures. Extracorporeal circulation is usually conducted by peripheral cannulation. Cross-clamp can be achieved by remote ways of either balloon endoclamp or transthoracic clamp. Effective delivery of cardioplegic solution is somewhat more difficult than those above mentioned tasks. In order to prevent additional expenses, we sought to deliver cardioplegic solution in a simple, reproducible, and cost-effective way. The miniport is used for this application. The procedures are reported in detail.

Spiral saphenous vein graft for portal vein reconstruction in pancreatic cancer surgery

The curative strategy for most pancreatic cancer is surgical resection. Extensive resection with lymph node dissection is the key to providing long-term survival. However, early diagnosis of pancreatic cancer is not always possible (ie, resectability is limited). One reason for such a nonresectable condition is vascular invasion or encasement. Portal vein involvement has been a contraindication for pancreatic cancer surgery for most general surgeons. Combining oncologic and vascular surgeons in the procedure has been a good solution. A multidisciplinary approach that includes general and vascular surgeons is appropriate in selected patients requiring vascular reconstruction at the time of pancreatectomy. The objective of this paper is to report a case in which spiral saphenous vein was used for portal vein reconstruction during pancreatic cancer resection.

More coronary artery stenosis, more cerebral artery stenosis? A simultaneous angiographic study discloses their strong correlation

Cerebral artery stenosis (CAS) has the same pathogenesis as coronary artery disease (CAD), but the coexistence of these two diseases has been rarely reported. To detect coexistent CAS in CAD patients, we conducted a study of simultaneous coronary and cerebral angiography. Of the 663 consecutive newly diagnosed CAD patients who had not yet been explored to have CAS, 80 were admitted to undergo angiography of bilateral carotid and vertebral system during the same procedure. We defined significant vascular stenosis, either located intracranially or extracranially, as the lesions of diameter stenosis more than 50%. Association between carotid or vertebral stenosis and their potential risk factors were also analyzed. Of our patients, 18 (22.5%) had significant extracranial vascular stenosis, 14 (17.5%) suffered from intracranial stenosis, and 20 (25%) had both. Only 28 patients (35%) had no significant intracranial or extracranial stenosis. None of the demographic parameters as hypertension or diabetes showed significant differences between the cerebral patent group and the CAS group, except for the number of coronary stenotic vessels (1.71 +/- 0.81 versus 2.69 +/- 0.64, P < 0.001). The number of coronary stenotic vessels is correlated well to the number of cerebral stenotic lesions (r = 0.562, P < 0.001). Besides, 8 of the cerebral stenotic patients and 2 of the cerebral patent patients had ischemic stroke previously. We conclude the CAS is coexistent in more than half of the CAD patients in this study. Our study also implies a proportional increase in the severity of CAS to CAD severity.

Clinical Features and Outcome of Tuberculosis in Solid Organ Transplant Recipients

BACKGROUND

: Taiwan is an area with moderate to high incidence of Mycobacterium tuberculosis infection. The risk of M tuberculosis infection in transplantation recipients is considered to be significant. Our aim in this study was to investigate the clinical spectrums of M tuberculosis-infected transplantation recipients in a southeast Asian country, Taiwan.

METHODS

: We retrospectively analyzed the demographic data, clinical features, treatment, and outcome of M tuberculosis infection in kidney, heart, and liver transplant recipients from May 1996 to April 2005 at the National Taiwan University Hospital.

RESULTS

: Fifteen patients who had received solid organ transplantation developed tuberculosis (kidney = 6, heart = 7, liver = 2). The median duration from transplantation to diagnosis of tuberculosis was 31 months. The cumulative incidence of post-transplantation tuberculosis was 2.0% (15/760), ie, approximately 3 times that of the general population. Ten patients (66.7%) had pulmonary tuberculosis, 1 (6.7%) had extrapulmonary tuberculosis, and 4 (26.7%) had disseminated tuberculosis. Nine patients completed the anti-tuberculosis treatment; the median treatment duration was 12 months (pulmonary: 9 months; extrapulmonary: 13.5 months). No treatment failure was noted in patients receiving the complete treatment course. The graft failure and mortality rates of post-transplantation tuberculosis were 13.3% each (2/15). The tuberculosis-associated mortality rate was 6.7% (1/15).

CONCLUSIONS

: Cumulative incidence of tuberculosis was slightly higher in transplant recipients than in the general population in Taiwan. Conventional 4-combined anti-tuberculosis regimen for 12 months can treat the potentially fatal infection successfully in post-transplantation tuberculosis patients without recurrence.

Carvedilol can restore the multifractal properties of heart beat dynamics in patients with advanced congestive heart failure

INTRODUCTION

Human heart beats in an extremely inhomogeneous and non-stationary manner. Recent study has demonstrated that it belongs to a class of signals called multifractal. Loss of multifractality was also uncovered in patients with congestive heart failure. We investigated whether carvedilol could restore the multifractal properties in a group of patients with advanced congestive heart failure.

METHODS AND RESULTS

A Holter ECG recording was obtained before and 1 and 3 months after titrated addition of carvedilol therapy in 10 patients with advanced congestive heart failure. Multifractal spectrum, detrended fluctuation analysis (DFA) as well as the traditional time- and frequency-domain heart rate variability (HRV) parameters were compared before and after carvedilol therapy together with those in age and sex-matched normal control. The results showed that the multifractal spectrum tau(q) vs. q of N-N interval time series returned toward normal during carvedilol treatment. All the traditional HRV parameters and the short-term DFA improved significantly after 3 months of carvedilol therapy.

CONCLUSION

We concluded that the deteriorated multifractal properties could be reversed by carvedilol treatment in patients with advanced congestive heart failure.

Immediate extubation in the operating room after cardiac operations with thoracotomy and sternotomy

BACKGROUND

Immediate extubation after cardiac operations in the operating room (OR) is rarely practised in Taiwan. The increased use of the minimally invasive and off-pump coronary artery bypass surgery (CABG) and the financial pressure from health insurance have raised the interest of its application after cardiac operations. The purpose of the study was to investigate the practice of immediate extubation in patients undergoing cardiac operations via minimal invasive thoracotomy against via midline sternotomy.

METHODS

Seventy unselected consecutive patients undergoing cardiac operations via either minimally invasive thoracotomy or midline sternotomy were enrolled for investigation. Anesthetic management, including bispectral index and continuous train-of-four (TOF) monitoring, was modified to extubate the patients in the OR within 15 min after the closure of the skin wound. Extubation criteria based on clear consciousness, recovery of muscle power, and stable hemodynamics without purposeful strong inotropic support were stipulated. Patient-controlled analgesia was used to provide adequate postoperative pain control.

RESULTS

Extubation within 15 min after the end of surgery was successful in all patients who underwent thoracotomy while there were five patients who could not be extubated in the sternotomy group. The PaCO2 values 30 min after extubation and the ICU stay were significantly higher and longer in patients of the sternotomy group. The pain intensity after extubation or the doses of analgesics used did not differ between two groups of patients. There was only one patient in the sternotomy group who needed reintubation and there was no postoperative death in both groups of patients.

CONCLUSIONS

We consider that immediate extubation after cardiac procedures either through thoracotomy or sternotomy is a rather safe practice and if possible minimally invasive technique should be chosen because it causes smaller wound and offers safer immediate extubation and shorter ICU stay.

Outcome for Pediatric Cardiac Transplantation With and Without Bridge Methods

Heart transplantation is indicated for children with end-stage heart failure or complex inoperable congenital defects. Due to the shortage of pediatric donor hearts, various bridge techniques have been used for pediatric recipients to prolong patient survival until a heart is available. This study evaluates long-term outcome of bridge and nonbridge support for pediatric heart transplantation. Between March 1995 and June 2004, 18 pediatric patients underwent heart transplantation. Six patients (33.3%) underwent biological or mechanical bridge techniques before transplantation. Eight patients (44.4%) required perioperatively extracorporeal membrane oxygenation (ECMO) support. Patient data and records were retrospectively reviewed. Causes of death and long-term outcome were analyzed. Five of eight patients in the ECMO group (62.5%) were successfully decannulated and discharged home with excellent functional classes. No differences in rejection rate, survival rate, and functional class existed between the bridged and nonbridged groups. Overall 1-year and 5-year survival rates were both 83.3% and all have a good functional class. Pediatric heart transplantation can be accomplished with excellent early survival despite multiple prior cardiac operations and relatively severe illness. For the variety in small, low-body-weight pediatric patients, mechanical circulatory support using ECMO is suitable for managing sudden collapse while waiting for heart transplantation, and graft dysfunction after cardiac transplantation. The mortality rate is acceptable in this very high-risk group of patients and long-term outcome is good.

Backpropagation Neural Network for Motion Analysis on Blood-pool Gated Single Photon Emission Computed Tomography

We used backpropagation neural network for left ventricular motion analysis on Tc-99m labeled RBC blood-pool gated single photon emission computed tomography (GSPECT). Phantom images by the model of solid spheres were generated to simulate the left ventricle. Training data sets were selected from the phantom images. After training, the neural network can perform motion analysis on the phantom images and all series of patients' GSPECT images. The results of motion analysis were displayed in the formats of vector fields superimposed on the original GSPECT images. The GSPECT of one patient with normal left ventricle and two patients with abnormal left ventricular motion were acquired and analyzed. The study showed that back propagation neural network was useful in the evaluation of left ventricular motion in GSPECT images.