Usefulness of Diagnostic Ultrasound for Detection of Common Shoulder Abnormalities Prior to MRI

Shoulder pain is a common musculoskeletal pain in the general population and results in significant disability, quality of life impairment and financial burden to the health care system. This cross-sectional study was carried out among purposively selected 61 adult patients with shoulder pain and or limited range of motion in the Department of Radiology and Imaging, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from September 2018 to August 2020 to determine the usefulness of USG in detection of common shoulder abnormalities, as an initial imaging modality using MRI as reference standard. The majority of the patients 25(40.98%) were in age group of 51-60 years with mean age of 52.98±10.85 years. In the dectection of rotator cuff pathology, the overall sensitivity, specificity and accuracy of USG for any complete tear were 100.0% each, for any partial tear were 79.71%, 96.57% and 91.80%, for any rotator cuff tear were 83.33%, 96.25% and 91.80%, and for any tendinosis were 90.48%, 99.37% and 96.31% respectively. The sensitivity, specificity and accuracy of USG were 88.23%, 92.59% & 90.16% for long head of biceps tendon sheath effusion, 100.0% each for long head of biceps tendon dislocation, 71.11%, 87.50% and 75.41% for glenohumeral joint effusion, and 58.06%, 96.67% and 77.05% for bursal effusion respectively. From this study, it is concluded that high resolution USG showed high sensitivity, specificity and accuracy compared to MRI in detecting common shoulder abnormalities, and could be considered as the first line imaging modality in the evaluation of shoulder pain.

Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium (B-Free): A Protocol for a Multi-centre Randomized Cluster Crossover Trial

Delirium is common after cardiac surgery and is associated with adverse outcomes. Administration of benzodiazepines before and after cardiac surgery is associated with delirium; guidelines recommend minimizing their use. Benzodiazepine administration during cardiac surgery remains common because of its recognized benefits. The Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium (B-Free) trial is a randomized cluster crossover trial evaluating whether an institutional policy of restricting intraoperative benzodiazepine administration (ie, ≥ 90% of patients do not receive benzodiazepines during cardiac surgery), as compared with a policy of liberal intraoperative benzodiazepine administration (ie, ≥ 90% of patients receive ≥ 0.03 mg/kg midazolam equivalent), reduces delirium. Hospitals performing ≥ 250 cardiac surgeries a year are included if their cardiac anesthesia group agrees to apply both benzodiazepine policies per their randomization, and patients are assessed for postoperative delirium every 12 hours in routine clinical care. Hospitals apply the restricted or liberal benzodiazepine policy during 12 to 18 crossover periods of 4 weeks each. Randomization for all periods takes place in advance of site startup; sites are notified of their allocated policy during the last week of each crossover period. Policies are applied to all patients undergoing cardiac surgery during the trial period. The primary outcome is the incidence of delirium at up to 72 hours after surgery. The B-Free trial will enroll ≥ 18,000 patients undergoing cardiac surgery at 20 hospitals across North America. Delirium is common after cardiac surgery, and benzodiazepines are associated with the occurrence of delirium. The B-Free trial will determine whether an institutional policy restricting the administration of benzodiazepines during cardiac surgery reduces the incidence of delirium after cardiac surgery. Clinicaltrials.gov registration number: NCT03928236 (First registered April 26, 2019).

Methemoglobin as a marker of acute anemic stress in cardiac surgery

Biological evidence supports plasma methemoglobin as a biomarker for anemia-induced tissue hypoxia. In this translational planned substudy of the multinational randomized controlled transfusion thresholds in cardiac surgery (TRICS-III) trial, which included adults undergoing cardiac surgery requiring cardiopulmonary bypass with a moderate-to-high risk of death, we investigated the relationship between perioperative hemoglobin concentration (Hb) and methemoglobin; and evaluated its association with postoperative outcomes. The primary endpoint was a composite of death, myocardial infarction, stroke, and severe acute kidney injury at 28 days. We observe weak non-linear associations between decreasing Hb and increasing methemoglobin, which were strongest in magnitude at the post-surgical time point. Increased levels of post-surgical methemoglobin were associated with a trend toward an elevated risk for stroke and exploratory neurological outcomes. Our generalizable study demonstrates post-surgical methemoglobin may be a marker of anemia-induced organ injury/dysfunction, and may have utility for guiding personalized approaches to anemia management. Clinicaltrials.gov registration NCT02042898.

Protocol for the electroencephalography guidance of anesthesia to alleviate geriatric syndromes (ENGAGES-Canada) study: A pragmatic, randomized clinical trial

Background:  There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery.  There is limited evidence in this regard for cardiac surgery.  A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death.  However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes. Methods:  The Electroe ncephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes ( ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites.  The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery.  One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25).  The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients.  The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review.  Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation. Discussion:  The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD. Registration: ClinicalTrials.gov ( NCT02692300) 26/02/2016.

Protocol for the electroencephalography guidance of anesthesia to alleviate geriatric syndromes (ENGAGES-Canada) study: A pragmatic, randomized clinical trial

Background:  There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery.  There is limited evidence in this regard for cardiac surgery.  A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death.  However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes. Methods:  The Electroe ncephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes ( ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites.  The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery.  One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25).  The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients.  The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review.  Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation. Discussion:  The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD. Registration: ClinicalTrials.gov ( NCT02692300) 26/02/2016.

Impact of inclusiveness on organizational commitment among employees of IT industry

Organizations continue to be challenged by diversity in their workforce. Hence it becomes imperative to nurture an inclusive workplace where all employees can co-exist and thrive. The primary objective of the current study is to examine the relationship between different constructs of inclusiveness and the organizational commitment of employees. Their search for the study is based on the data collected from multiple IT organizations across major cities (Delhi, Mumbai, Bangalore, and Pune) of India. A structured questionnaire was distributed. Multiple regression analysis was applied on the primary data obtained from 160 respondents to interpret the impact on the organizational commitment by different constructs of inclusiveness. The results from the study reveal that different constructs of inclusiveness (supervisor role, relationship with co-workers, and organizational practices) have a significant effect on the organizational commitment of an employee. The study highlights the importance of creating a sense of acceptance among employees of an organization through inclusive work culture, which ultimately enhances the commitment level of employees towards their organization.

Psychological Assessment of Health-Care Workers Working during COVID-19 Pandemic Condition in Bangladesh

The study was aimed to assess the psychological aspects and relevant factors of the health-care workers (HCWs) working in COVID 19 pandemic condition in Bangladesh. This online cross-sectional survey was conducted from different tertiary, secondary and primary hospitals in Bangladesh. Eligible 638 HCWs who were directly involved in the caring of confirmed or suspected COVID-19 patients were recruited in this study. The mental health was assessed by the Patient Health Questionnare-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) and Athens Insomnia Scale (AIS). High frequency of depression 536(84.0%), anxiety 386(60.5%) and insomnia 302(47.3%) was found among the HCWs, which were significantly higher in physicians (p<0.001) than nurses. Moderate to severe depression was significantly higher in female, whereas minimal to mild depression was significant in male HCWs (p=0.014). Symptoms of depression (p<0.001), anxiety (p<0.001) and insomnia (p=0.004) were significantly higher among the HCWs of primary and secondary compared to the tertiary level. The HCWs developed psychological trauma due to family health (45.3%) and contagious disease property (66.6%). After adjusting confounders, multivariable logistic regression analysis showed that physicians and HCWs of secondary hospital had significant symptoms of severe depression (OR=2.95, 95% CI=0.50-17.24; p<0.001), anxiety (OR=2.64, 95% CI=0.80-8.72; p<0.001) and insomnia (OR=2.67, 95% CI=1.23-5.84; p=0.018); whereas female HCWs had more risk of developing symptoms of severe insomnia (OR= 1.84; 95% CI=1.23-2.75; p=0.003). High rate of depression, anxiety and insomnia was found among HCWs working in the COVID-19 pandemic condition in this survey.

Restrictive versus liberal transfusion in patients with diabetes undergoing cardiac surgery: An open-label, randomized, blinded outcome evaluation trial

AIM

To characterize the association between diabetes and transfusion and clinical outcomes in cardiac surgery, and to evaluate whether restrictive transfusion thresholds are harmful in these patients.

MATERIALS AND METHODS

The multinational, open-label, randomized controlled TRICS-III trial assessed a restrictive transfusion strategy (haemoglobin [Hb] transfusion threshold <75 g/L) compared with a liberal strategy (Hb <95 g/L for operating room or intensive care unit; or <85 g/L for ward) in patients undergoing cardiac surgery on cardiopulmonary bypass with a moderate-to-high risk of death (EuroSCORE ≥6). Diabetes status was collected preoperatively. The primary composite outcome was all-cause death, stroke, myocardial infarction, and new-onset renal failure requiring dialysis at 6 months. Secondary outcomes included components of the composite outcome at 6 months, and transfusion and clinical outcomes at 28 days.

RESULTS

Of the 5092 patients analysed, 1396 (27.4%) had diabetes (restrictive, n = 679; liberal, n = 717). Patients with diabetes had more cardiovascular disease than patients without diabetes. Neither the presence of diabetes (OR [95% CI] 1.10 [0.93-1.31]) nor the restrictive strategy increased the risk for the primary composite outcome (diabetes OR [95% CI] 1.04 [0.68-1.59] vs. no diabetes OR 1.02 [0.85-1.22]; P_interaction  = .92). In patients with versus without diabetes, a restrictive transfusion strategy was more effective at reducing red blood cell transfusion (diabetes OR [95% CI] 0.28 [0.21-0.36]; no diabetes OR [95% CI] 0.40 [0.35-0.47]; P_interaction  = .04).

CONCLUSIONS

The presence of diabetes did not modify the effect of a restrictive transfusion strategy on the primary composite outcome, but improved its efficacy on red cell transfusion. Restrictive transfusion triggers are safe and effective in patients with diabetes undergoing cardiac surgery.

Quantifying neurological function in patients undergoing transcatheter aortic valve implantation

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Elderly patients undergoing transcatheter aortic valve implantation can experience post-operative neurological impairments.

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Cutting-edge robotic assessments may help detect neurocognitive dysfunction in this patient population.

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By quantifying neurological functioning before and after surgery, a diverse array of impairments can be uncovered.

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Future studies using robotic technology can help determine predictors of neurological functioning in surgical patients.

Background

Transcatheter aortic valve implantation (TAVI) is a routine procedure that is often performed on older adults that are high-risk patients with severe aortic stenosis. Patients after TAVI may experience neurological complications. However, there is a lack of objective neurological testing available for patients undergoing cardiac surgery.

Objective

This brief communication seeks to explore the use of robotic technology to quantify distinctive patterns of visuospatial, sensorimotor, and cognitive functioning in patients undergoing TAVI.

Methods

Patients undergoing TAVI were recruited for this prospective observational study. Prior to their procedure, study participants performed four robotic reaching tasks using the Kinarm robotic system. Patients repeated the assessment three months after their TAVI procedure. Significant changes in overall task score and parameters were determined.

Results

Ten patients were recruited and included in this brief report. In a simple reaching task, patients show significant improvement in performance post-TAVI. However, patients do not improve nor worsen in a complex reaching task after TAVI. Similarly, patients demonstrate impairments in both trail making tasks before and after their TAVI procedure.

Conclusions

This study captures the variability in neurological functioning in older patients undergoing TAVI. Robotic technology and quantified assessment procedures can be extremely valuable for detecting perioperative neurological impairments in this patient population.

Utility of telemetry in syncope admissions

Introduction

Syncope is a major cause of emergency room visits and admission to telemetry units however, prior studies have shown conflicting evidence for the necessity for a telemetry admission. Our current 2017 ACC/AHA/HRS guidelines recommend telemetry admissions for syncope evaluation when cardiac etiology is suspected.

Purpose

The purpose of this study is to investigate whether there are any differences in telemetry events in patients with a cardiac syncope versus non-cardiac/unspecified and to determine any correlation between the number of cardiac risk factors in patients with cardiac syncope versus non-cardiac etiology to predict those who would benefit most from telemetry.

Methods

Our retrospective study included 574 patients admitted to the cardiac telemetry unit between February 2017 and February 2020 at our metropolitan tertiary care centre, further grouped into: cardiac, non-cardiac, or unspecified syncope. Cardiac syncope included aetiologies such as arrhythmias, pulmonary hypertension, Long QTc, device malfunction etc. The non-cardiac syncope group included aetiologies such as orthostatic and reflex mediated. Thirteen cardiac risk factors were summed from the 2009 ESC syncope guidelines. These included HFrEF, elevated BNP, anemia, abnormal ECG, family history of sudden cardiac death or MI, age above 65, male gender, structural heart disease, abnormal vitals on presentation, history of sudden cardiac death, no prodrome prior to syncope and chest pain.

Results

Of the 574 patients, 102 patients (17.7%) had a cardiac etiology, 405 patients (70.5%) had a non-cardiac etiology and 67 patients (11.6%) had unspecified etiology for syncope. Overall, 47% of the cardiac group, 16% of the non-cardiac group, and 12% of the unspecified group had telemetry events. There was a statistically significant difference in the number of patients with telemetry events among the three syncope groups, p&lt;0.0001. The odds of patients with cardiac syncope having telemetry events were 4.0 times greater than those with non-cardiac syncope and 6.3 time higher than those with unspecified syncope.

The average number of risk factors were: 4 (±1.7) (cardiac), 3±1.6 (non-cardiac), and 3±1.7 (unspecified). Linear regression model showed the number of risk factors to be 19% and 15% lower in the non-cardiac and unspecified groups compared to the cardiac group. There was no association between any of the individual risk factors and the presence of telemetry event.

Conclusions

Our study demonstrates that those with cardiac syncope tend to have more cardiac risk factors and more telemetry events relative to their non-cardiac syncope counterparts. While patients with cardiac risk factors have on average a higher cardiac risk factor profile, it is not clinically significant enough to determine who would benefit from telemetry versus who would not.

Funding Acknowledgement

Type of funding sources: None.

Effect of Continuous Electrocardiogram Monitoring on Detection of Undiagnosed Atrial Fibrillation After Hospitalization for Cardiac Surgery: A Randomized Clinical Trial

IMPORTANCE

Postoperative atrial fibrillation (POAF) occurring after cardiac surgery is associated with adverse outcomes. Whether POAF persists beyond discharge is not well defined.

OBJECTIVE

To determine whether continuous cardiac rhythm monitoring enhances detection of POAF among cardiac surgical patients during the first 30 days after hospital discharge compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

This study is an investigator-initiated, open-label, multicenter, randomized clinical trial conducted at 10 Canadian centers. Enrollment spanned from March 2017 to March 2020, with follow-up through September 11, 2020. As a result of the COVID-19 pandemic, enrollment stopped on July 17, 2020, at which point 85% of the proposed sample size was enrolled. Cardiac surgical patients with CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex) score greater than or equal to 4 or greater than or equal to 2 with risk factors for POAF, no history of preoperative AF, and POAF lasting less than 24 hours during hospitalization were enrolled.

INTERVENTIONS

The intervention group underwent continuous cardiac rhythm monitoring with wearable, patch-based monitors for 30 days after randomization. Monitoring was not mandated in the usual care group within 30 days after randomization.

MAIN OUTCOMES AND MEASURES

The primary outcome was cumulative AF and/or atrial flutter lasting 6 minutes or longer detected by continuous cardiac rhythm monitoring or by a 12-lead electrocardiogram within 30 days of randomization. Prespecified secondary outcomes included cumulative AF lasting 6 hours or longer and 24 hours or longer within 30 days of randomization, death, myocardial infarction, ischemic stroke, non-central nervous system thromboembolism, major bleeding, and oral anticoagulation prescription.

RESULTS

Of the 336 patients randomized (163 patients in the intervention group and 173 patients in the usual care group; mean [SD] age, 67.4 [8.1] years; 73 women [21.7%]; median [interquartile range] CHA2DS2-VASc score, 4.0 [3.0-4.0] points), 307 (91.4%) completed the trial. In the intent-to-treat analysis, the primary end point occurred in 32 patients (19.6%) in the intervention group vs 3 patients (1.7%) in the usual care group (absolute difference, 17.9%; 95% CI, 11.5%-24.3%; P < .001). AF lasting 6 hours or longer was detected in 14 patients (8.6%) in the intervention group vs 0 patients in the usual care group (absolute difference, 8.6%; 95% CI, 4.3%-12.9%; P < .001).

CONCLUSIONS AND RELEVANCE

In post-cardiac surgical patients at high risk of stroke, no preoperative AF history, and AF lasting less than 24 hours during hospitalization, continuous monitoring revealed a significant increase in the rate of POAF after discharge that would otherwise not be detected by usual care. Studies are needed to examine whether these patients will benefit from oral anticoagulation therapy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02793895.

Enrichment of laccase production by Phoma herbarum isolate KU4 under solid-state fermentation by optimizing RSM coefficients using genetic algorithm

The process parameters were optimized to obtain enhanced enzyme activity from the fungus Phoma herbarum isolate KU4 using rice straw and saw dust as substrate under solid-state fermentation using Response surface methodology (RSM). Genetic algorithm was used to validate the RSM for maximum laccase production. Six variables, viz., pH of the media, initial moisture content, copper sulphate concentration, concentration of tannic acid, inoculum concentration and incubation time were found to be effective and optimized for enhanced production. Maximum laccase production was achieved by RSM at pH 5·0 and 86% of initial moisture content of the culture medium, 150 µmol l^-1 of CuSO₄ , 1·5% tannic acid and 0·128 g inoculum g^-1 dry substrate inoculum size on the fourth day of fermentation. The highest laccase activity was observed as 79 008 U g^-1 , which is approximately sixfold enhanced production compared to the unoptimized condition (12 085·26 U g^-1 ).

Cognitive Outcomes after DEXmedetomidine sedation in cardiac surgery: CODEX randomised controlled trial protocol

INTRODUCTION

Older patients undergoing cardiac surgery carry the highest risk for developing major postoperative neurocognitive disorder (postoperative NCD or P-NCD) with up to 25% incidence 3 months after surgery. P-NCD is associated with significant morbidity, mortality, loss of independence, premature retirement and increased healthcare costs. This multicentre randomised trial is investigating the efficacy of postoperative dexmedetomidine sedation in reducing the incidence of major P-NCD after cardiac surgery compared with standard protocols. CODEX will be the largest interventional trial with major P-NCD as the primary outcome.

METHODS AND ANALYSIS

CODEX is recruiting patients ≥60 years old, undergoing elective cardiac surgery and without pre-existing major cognitive dysfunction or dementia. Eligible participants are randomised to receive postoperative dexmedetomidine or standard institutional sedation protocols in the intensive care unit. Baseline preoperative cognitive function is assessed with the computer-based Cogstate Brief Battery. The primary outcome, major P-NCD, 3 months after surgery is defined as a decrease in cognitive function ≥1.96 SD below age-matched, non-operative controls. Secondary outcomes include delirium, major P-NCD at 6/12 months, depressive symptoms, mild P-NCD and quality of surgical recovery at 3/6/12 months. The specific diagnostic criteria used in this protocol are consistent with the recommendations for clinical assessment and management of NCD from the Nomenclature Consensus Working Group on perioperative cognitive changes. Intention-to-treat analysis will compare major P-NCD at 3 months between study groups.

ETHICS AND DISSEMINATION

CODEX was approved by Sunnybrook Health Sciences Centre Research Ethics Board (REB) (Project ID 1743). This will be the first multicentre, randomised controlled trial to assess the efficacy of a pharmacological intervention to reduce the incidence of major P-NCD after cardiac surgery in patients ≥60 years old. Dissemination of the study results will include briefings of key findings and interpretation, conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT04289142.

Quantified pre-operative neurological dysfunction predicts outcome after coronary artery bypass surgery

AIMS

Patients undergoing coronary artery bypass grafting (CABG) surgery may experience neurological impairment. We examined whether intraoperative regional cerebral oxygen saturation (rSO₂) and neurological dysfunction prior to surgery, measured by robotic technology, are important predictors of post-operative performance following CABG surgery.

METHODS

Adult patients undergoing CABG surgery were recruited for this single-center prospective observational study. Intraoperative rSO₂ was captured using the FORESIGHT cerebral oximeter. Neurological assessment was performed pre-operatively and 3 months following surgery using robotic technology and a standardized pen-and-paper assessment. Linear regression models were generated to determine the predictive ability of both intraoperative rSO₂ and pre-operative performance on post-operative neurological outcome.

RESULTS

Forty patients had complete data available for analysis. Quantified pre-operative performance accounted for a significantly larger amount of variance in post-operative outcome compared to intraoperative rSO₂. In particular, pre-operative scoring on a cognitive visuospatial task accounted for 82.2% of variance in post-operative performance (b = 0.937, t(37) = 12.98, p = 1.28e-5).

DISCUSSION

Our results suggest that pre-operative performance is a stronger indicator of post-operative neurological outcome than intraoperative rSO₂, and should be included as an important variable when elucidating the relationship between cerebral oxygen levels and post-operative neurological impairment. Rigorous neurological assessment prior to surgery can provide valuable information about each individual patient's path to recovery.

CONCLUSION

Using robotic technology, quantified neurological impairment prior to CABG surgery may better predict post-operative neurological outcomes, compared to intraoperative rSO₂ values.

Road to recovery: a study protocol quantifying neurological outcome in cardiac surgery patients and the role of cerebral oximetry

INTRODUCTION

Patients undergoing cardiac surgery may experience both short-term and long-term postoperative neurological problems. However, the underlying cause of this impairment is unclear. Regional cerebral oxygen saturation (rSO₂) levels may play a role in the development of acute dysfunction, known as postoperative delirium, in addition to longer term outcomes after cardiac surgery. Yet the degree of impairment has been difficult to define, partly due to subjective methods of assessments. This study aims to fill this knowledge gap by determining the relationship between rSO₂, postoperative delirium and long-term neurological outcome after cardiac surgery using quantitative robotic technology.

METHODS AND ANALYSIS

95 patients scheduled for elective cardiac surgery will be recruited for this single-centre prospective observational study. Patients will be assessed before as well as 3 and 12 months after their surgery using the Kinarm End-Point Lab and standardised tasks. Intraoperatively, rSO₂ and other haemodynamic data will be collected for the duration of the procedure. Following their operation, patients will also be screened daily for delirium during their hospital stay.

ETHICS AND DISSEMINATION

This study has been approved by the Health Sciences Research Ethics Board at Queen's University (DMED-1672-14). The results of this study will be published in a peer-review journal and presented at international and/or national conferences as poster or oral presentations. Participants wishing to know the results of this study will be contacted directly on data publication.

TRIAL REGISTRATION NUMBER

NCT04081649.

Effect of Fibrinogen Concentrate vs Cryoprecipitate on Blood Component Transfusion After Cardiac Surgery: The FIBRES Randomized Clinical Trial

IMPORTANCE

Excessive bleeding is a common complication of cardiac surgery. An important cause of bleeding is acquired hypofibrinogenemia (fibrinogen level <1.5-2.0 g/L), for which guidelines recommend fibrinogen replacement with cryoprecipitate or fibrinogen concentrate. The 2 products have important differences, but comparative clinical data are lacking.

OBJECTIVE

To determine if fibrinogen concentrate is noninferior to cryoprecipitate for treatment of bleeding related to hypofibrinogenemia after cardiac surgery.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial at 11 Canadian hospitals enrolling adult patients experiencing clinically significant bleeding and hypofibrinogenemia after cardiac surgery (from February 10, 2017, to November 1, 2018). Final 28-day follow-up visit was completed on November 28, 2018.

INTERVENTIONS

Fibrinogen concentrate (4 g; n = 415) or cryoprecipitate (10 units; n = 412) for each ordered dose within 24 hours after cardiopulmonary bypass.

MAIN OUTCOMES AND MEASURES

Primary outcome was blood components (red blood cells, platelets, plasma) administered during 24 hours post bypass. A 2-sample, 1-sided test for the ratio of the mean number of units was conducted to evaluate noninferiority (threshold for noninferiority ratio, <1.2).

RESULTS

Of 827 randomized patients, 735 (372 fibrinogen concentrate, 363 cryoprecipitate) were treated and included in the primary analysis (median age, 64 [interquartile range, 53-72] years; 30% women; 72% underwent complex operations; 95% moderate to severe bleeding; and pretreatment fibrinogen level, 1.6 [interquartile range, 1.3-1.9] g/L). The trial met the a priori stopping criterion for noninferiority at the interim analysis after 827 of planned 1200 patients were randomized. Mean 24-hour postbypass allogeneic transfusions were 16.3 (95% CI, 14.9 to 17.8) units in the fibrinogen concentrate group and 17.0 (95% CI, 15.6 to 18.6) units in the cryoprecipitate group (ratio, 0.96 [1-sided 97.5% CI, -∞ to 1.09; P < .001 for noninferiority] [2-sided 95% CI, 0.84 to 1.09; P = .50 for superiority]). Thromboembolic events occurred in 26 patients (7.0%) in the fibrinogen concentrate group and 35 patients (9.6%) in the cryoprecipitate group.

CONCLUSIONS AND RELEVANCE

In patients undergoing cardiac surgery who develop clinically significant bleeding and hypofibrinogenemia after cardiopulmonary bypass, fibrinogen concentrate is noninferior to cryoprecipitate with regard to number of blood components transfused in a 24-hour period post bypass. Use of fibrinogen concentrate may be considered for management of bleeding in patients with acquired hypofibrinogenemia in cardiac surgery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03037424.

[Knowledge retention after focused cardiac ultrasound training: a prospective cohort pilot study]

BACKGROUND AND OBJECTIVES

Focused Cardiac Ultrasound (FoCUS) has proven instrumental in guiding anesthesiologists' clinical decision-making process. Training residents to perform and interpret FoCUS is both feasible and effective. However, the degree of knowledge retention after FoCUS training remains a subject of debate. We sought to provide a description of our 4-week FoCUS curriculum, and to assess the knowledge retention among anesthesia residents at 6 months after FoCUS rotation.

METHODS

A prospective analysis involving eleven senior anesthesia residents was carried out. At end of FoCUS Rotation (EOR) participants completed a questionnaire (evaluating the number of scans completed and residents' self-rated knowledge and comfort level with FoCUS), and a multiple-choice FoCUS exam comprised of written- and video-based questions. Six months later, participants completed a follow-up questionnaire and a similar exam. Self-rated knowledge and exam scores were compared at EOR and after 6 months. Spearman correlations were conducted to test the relationship between number of scans completed and exam scores, perceived knowledge and exam scores, and number of scans and perceived knowledge.

RESULTS

Mean exam scores (out of 50) were 44.1 at EOR and 43 at the 6-month follow-up. Residents had significantly higher perceived knowledge (out of 10) at EOR (8.0) than at the 6-month follow-up (5.5), p=0.003. At the EOR, all trainees felt comfortable using FoCUS, and at 6 months 10/11 still felt comfortable. All the trainees had used FoCUS in their clinical practice after EOR, and the most cited reason for not using FoCUS more frequently was the lack of perceived clinical need. A strong and statistically significant (rho=0.804, p=0.005) correlation between number of scans completed during the FoCUS rotation and 6-month follow-up perceived knowledge was observed.

CONCLUSION

Four weeks of intensive FoCUS training results in adequate knowledge acquisition and 6-month knowledge retention.

The relationship between cerebral oxygen saturation and quantitative metrics of neurological function after coronary bypass surgery: a feasibility study

BACKGROUND

It is well-known that patients undergoing coronary artery bypass grafting (CABG) surgery may experience neurological dysfunction following their operation. However, the nature of this dysfunction has not been properly quantified. Furthermore, the relationship between postoperative impairment and cerebral oxygen saturation during surgery has remained unclear. This study aims to define the feasibility of using robotic technology to quantify post-CABG neurocognitive function, and to correlate these objective metrics with intraoperative cerebral oxygenation.

METHODS

Neurological function was tested using robotic technology and a standardized questionnaire before and 3 months after surgery. In addition, frontal lobe cerebral oxygenation was recorded using the FORESIGHT near-infrared spectrometer for the duration of the operation. Pre- and postoperative neurological assessment was performed for 24 participants. Of those 24, 20 participants had cerebral oxygenation recorded during their surgery.

RESULTS

The cerebral oximeter captured 97.2% of the data. Majority of patients experienced no significant decline in overall neurocognitive function. Abnormal postoperative scores were most frequent in a sensorimotor task that involved additional cognitive load. In this reverse visually guided reaching task, postoperative scores significantly correlated with mean and minimum intraoperative cerebral oxygenation values, with lower values being associated with worse performance.

CONCLUSIONS

It is feasible to use robotic technology as a quantitative and objective neurocognitive assessment method for patients undergoing CABG. The relationship between quantitative metrics of neurocognitive function and intraoperative cerebral oxygenation warrants further investigation.

Additional synthesis on thiophene-containing trisubstituted methanes (TRSMs) as inhibitors of M. tuberculosis and 3D-QSAR studies

We earlier reported thiophene-containing trisubstituted methanes (TRSMs) as novel cores carrying anti-tubercular activity, and identified S006-830 as the phenotypic lead with potent bactericidal activity against single- and multi-drug resistant clinical isolates of Mycobacterium tuberculosis (M. tb). In this work, we carried out additional synthesis of several TRSMs. The reaction scheme essentially followed the Grignard reaction and Friedel-Crafts alkylation, followed by insertion of a dialkylaminoethyl chain. We also performed microbiological evaluations including in vitro screening against the virulent strain M. tb H37Rv, cytotoxicity assessment in the Vero C-1008 cell line, and 3D-QSAR studies with comparative molecular field analysis (CoMFA) and comparative molecular similarity index analysis (CoMSIA). CoMFA and CoMSIA models yielded good statistical results in terms of q² and r² values, suggesting the validity of the models. It was concluded that a para-substituted benzene ring with bulkier electron-donating groups and aminoalkyl chains are required for higher inhibitory capacity against M. tuberculosis. We believe that these insights will rationally guide the design of newer, optimal, TRSMs.

Periarticular Morphine-Induced Sphincter of Oddi Spasm Causing Severe Pain and Bradycardia in an Awake Patient Under Spinal Anesthesia: An Important Diagnostic Consideration

Sphincter of Oddi spasm from opioids has been documented, presenting as severe epigastric pain and potentially overlooked in a differential diagnosis. We present a case of sphincter of Oddi spasm from periarticular morphine in a patient under spinal anesthesia, causing severe distress and treated effectively with glucagon. It is important for anesthesiologists using opioids to consider it as a cause of perioperative pain and be familiar with treatment as it may be refractory by conventional use of opioids for pain relief. It is also important to consider the systemic effects of periarticular absorption, as evident by our case.

Molecular evolution and functional characterisation of haplotypes of an important rubber biosynthesis gene in Hevea brasiliensis

Hydroxy-methylglutaryl coenzyme-A synthase (HMGS) is a rate-limiting enzyme in the cytoplasmic isoprenoid biosynthesis pathway leading to natural rubber production in Hevea brasiliensis (rubber). Analysis of the structural variants of this gene is imperative to understand their functional significance in rubber biosynthesis so that they can be properly utilised for ongoing crop improvement programmes in Hevea. We report here allele richness and diversity of the HMGS gene in selected popular rubber clones. Haplotypes consisting of single nucleotide polymorphisms (SNPs) from the coding and non-coding regions with a high degree of heterozygosity were identified. Segregation and linkage disequilibrium analysis confirmed that recombination is the major contributor to the generation of allelic diversity, rather than point mutations. The evolutionarily conserved nature of some SNPs was identified by comparative DNA sequence analysis of HMGS orthologues from diverse taxa, demonstrating the molecular evolution of rubber biosynthesis genes in general. In silico three-dimensional structural studies highlighting the structural positioning of non-synonymous SNPs from different HMGS haplotypes revealed that the ligand-binding site on the enzyme remains impervious to the reported sequence variations. In contrast, gene expression results indicated the possibility of association between specific haplotypes and HMGS expression in Hevea clones, which may have a downstream impact up to the level of rubber production. Moreover, haplotype diversity of the HMGS gene and its putative association with gene expression can be the basis for further genetic association studies in rubber. Furthermore, the data also show the role of SNPs in the evolution of candidate genes coding for functional traits in plants.

A pilot study on the contribution of folate gene variants in the cognitive function of ADHD probands

Genetic abnormalities in components important for the folate cycle confer risk for various disorders since adequate folate turnover is necessary for normal methylation, gene expression and chromosome structure. However, the system has rarely been studied in children diagnosed with attention deficit hyperactivity disorder (ADHD). We hypothesized that ADHD related cognitive deficit could be attributed to abnormalities in the folate cycle and explored functional single nucleotide polymorphisms in methylenetetrahydrofolate dehydrogenase (rs2236225), reduced folate carrier (rs1051266), and methylenetetrahydrofolate reductase (rs1801131 and rs1801133) in families with ADHD probands (N = 185) and ethnically matched controls (N = 216) recruited following the DSM-IV. After obtaining informed written consent for participation, peripheral blood was collected for genomic DNA isolation and PCR-based analysis of target sites. Data obtained was analyzed by UNPHASED. Interaction between sites was analyzed by the multi dimensionality reduction (MDR) program. Genotypic frequencies of the Indian population were strikingly different from other ethnic groups. rs1801133 "T" allele showed biased transmission in female probands (p < 0.05). Significant difference in genotypic frequencies for female probands was also noticed. rs1801131 and rs1801133 showed an association with low intelligence quotient (IQ). MDR analysis exhibited independent effects and contribution of these sites to IQ, thus indicating a role of these genes in ADHD related cognitive deficit.

An urban, water-borne outbreak of diarrhoea and shigellosis in a district town in eastern India

BACKGROUND

In September 2007, the Gayeshpur municipality reported a cluster of cases with diarrhoea. We aimed to identify the causative agent and the source of the disease.

METHODS

We defined a case as the occurrence of diarrhoea (> 3 loose stools/day) with fever or bloody stools in a resident of Gayeshpur in September-October 2007. We asked healthcare facilities to report cases, collected stool specimens from patients, constructed an epidemic curve, drew a map and calculated the incidence by age and sex. We also conducted a matched case-control study (58 in each group), calculated matched odds ratio (MOR) and population attributable fraction (PAF), as well as assessed the environment.

RESULTS

We identified 461 cases (attack rate: 46/1000 population) and isolated Shigella flexneri (serotype 2a and 3a) from 3 of 4 stool specimens. The attack rate was higher among females (52/1000) and those in the age group of 45-59 years (71/1000). The outbreak started on 22 September, peaked multiple times and subsided on 12 October 2007. Cases were clustered distal to a leaking pipeline that crossed an open drain to intermittently supply non-chlorinated water to taps. The 58 cases and 58 controls were matched for age and sex. Drinking tap water (MOR: 10; 95% CI: 3-32; PAF: 89%), washing utensils in tap water (MOR: 3.7; 95% CI: 1.2-11.3) and bathing in tap water (MOR: 3.5; 95% CI: 1.1-11) were associated with the illness.

CONCLUSION

This outbreak of diarrhoea and Shigella flexneri dysentery was caused by contamination of tap water and subsided following repair of the pipeline. We recommended regular chlorination of the water and maintenance of pipelines.

Assessment of the impact of pesticide residues on microbiological and biochemical parameters of tea garden soils in India

The main aim of this study was to assess the impact of pesticidal residues on soil microbial and biochemical parameters of the tea garden soils. The microbial biomass carbon (MBC), basal (BSR) and substrate induced respirations (SIR), beta-glucosidase activity and fluorescein diacetate hydrolyzing activity (FDHA) of six tea garden soils, along with two adjacent forest soils (control) in West Bengal, India were measured. The biomass and its activities and biochemical parameters were generally lower in the tea garden soils than the control soils. The MBC of the soils ranged from 295.5 to 767.5 micro g g(- 1). The BSR and SIR ranged from 1.65 to 3.08 mu g CO2-C g(- 1) soil h(- 1) and 3.08 to 10.76 micro g CO2-C g(- 1)h(- 1) respectively. The beta-glucosidase and FDHA of the soils varied from 33.3 and 76.3 micro g para-nitrophenol g(- 1) soil h(- 1) and 60.5 to 173.5 micro g fluorescein g(- 1)h(- 1)respectively. The tea garden soils contained variable residues of organophosphorus and organochlorine pesticides, which negatively affected the MBC, BSR, SIR, FDHA and beta -glucosidase activity. Ethion and chlorpyriphos pesticide residues in all the tea garden soils varied from 5.00 to 527.8 ppb and 17.6 to 478.1 ppb respectively. The alpha endosulfan, beta endosulfan and endosulfan sulfate pesticide residues in the tea garden soils ranged from 7.40 to 81.40 ppb, 8.50 to 256.1 ppb and 55 to 95.9 ppb respectively. Canonical correlation analysis shows that 93% of the total variation was associated with the negative impact of chlorpyriphos, beta and alpha endosulfan and endosulfan sulfate on MBC, BSR and FDHA. At the same time ethion had negative impact on SIR and beta-glucosidase. Data demonstrated that the pesticide residues had a strong impact on the microbial and biochemical components of soil quality.

RING finger-dependent ubiquitination by PRAJA is dependent on TGF-beta and potentially defines the functional status of the tumor suppressor ELF

In gastrointestinal cells, biological signals for transforming growth factor-beta (TGF-beta) are transduced through transmembrane serine/threonine kinase receptors that signal to Smad proteins. Smad4, a tumor suppressor, is often mutated in human gastrointestinal cancers. The mechanism of Smad4 inactivation, however, remains uncertain and could be through E3-mediated ubiquitination of Smad4/adaptor protein complexes. Disruption of ELF (embryonic liver fodrin), a Smad4 adaptor protein, modulates TGF-beta signaling. We have found that PRAJA, a RING-H2 protein, interacts with ELF in a TGF-beta-dependent manner, with a fivefold increase of PRAJA expression and a subsequent decrease in ELF and Smad4 expression, in gastrointestinal cancer cell lines (P < 0.05). Strikingly, PRAJA manifests substantial E3-dependent ubiquitination of ELF and Smad3, but not Smad4. Delta-PRAJA, which has a deleted RING finger domain at the C terminus, abolishes ubiquitination of ELF. A stable cell line that overexpresses PRAJA exhibits low levels of ELF in comparison to a Delta-PRAJA stable cell line, where ELF expression is high compared to normal controls. The alteration of ELF and/or Smad4 expression and/or function in the TGF-beta signaling pathway may be induced by enhancement of ELF degradation, which is mediated by a high-level expression of PRAJA in gastrointestinal cancers. In hepatocytes, half-life (t(1/2)) and rate constant for degradation (k(D)) of ELF is 1.91 h and 21.72 min(-1) when coupled with ectopic expression of PRAJA in cells stimulated by TGF-beta, compared to PRAJA-transfected unstimulated cells (t(1/2) = 4.33 h and k(D) = 9.6 min(-1)). These studies reveal a mechanism for tumorigenesis whereby defects in adaptor proteins for Smads, such as ELF, can undergo degradation by PRAJA, through the ubiquitin-mediated pathway.

Wastewater quality status of the Tally nulla in Calcutta

The study of the Tally nulla wastewater system showed that the entire canal system is completely anoxic and unsuitable for sustaining aquatic life. Color and odor have exceeded the threshold limit. Tidal exchange is seemed to take place only up to six km. from the confluence zone of the river hooghly. Beyond this, comparatively higher ionic load in the water mass is encountered in both seasons. The fresh water during rainy season decreases the chemical load by dilution along with an increase in bacterial populations in the system indicating significant contamination with disease causing bacteria and pollution with excreta. This may become environmental hazards of the public health in course of any type of interaction with the waste water.

Tetraplex formation by the progressive myoclonus epilepsy type-1 repeat: implications for instability in the repeat expansion diseases

The repeat expansion diseases are a group of genetic disorders resulting from an increase in size or expansion of a specific array of tandem repeats. It has been suggested that DNA secondary structures are responsible for this expansion. If this is so, we would expect that all unstable repeats should form such structures. We show here that the unstable repeat that causes progressive myoclonus epilepsy type-1 (EPM1), like the repeats associated with other diseases in this category, forms a variety of secondary structures. However, EPM1 is unique in that tetraplexes are the only structures likely to form in long unpaired repeat tracts under physiological conditions.

Volume-outcome relationships in cardiovascular operations: New York State, 1990-1995

BACKGROUND

It has been known for nearly 20 years that, in cardiovascular operations, a significant inverse relationship exists between clinical outcomes and the volume of procedures performed. Interestingly, this relationship persists 2 decades after it was recognized.

OBJECTIVE

The purpose of this study was to examine the relationship between hospital volume and in-hospital deaths in 3 cardiovascular procedures: coronary artery bypass grafting, elective repair of abdominal aortic aneurysms, and repair of congenital cardiac defects.

METHODS

The database includes all patients who were hospitalized in New York State during the years 1990 to 1995. Using standard logistic regression techniques, we analyzed the relationship between hospital volume and outcome.

RESULTS

No correlation exists between hospital volume and in-hospital deaths in coronary artery bypass grafting. Statewide, 31 hospitals performed 97,137 operations over the 6-year period (overall mortality rate, 2. 75%). By contrast, most of the hospitals statewide (195 of 230 hospitals) performed 9847 elective abdominal aortic aneurysm repairs with an overall mortality rate of 5.5%. In abdominal aortic aneurysm operations, a significant inverse relationship between hospital volume and in-hospital deaths was determined. Sixteen hospitals performed 7199 repairs for congenital cardiac defects. A significant inverse relationship (which was most pronounced for neonates) was found between volume and death.

CONCLUSIONS

The importance of these findings lies in the rather striking difference between the volume-outcome relationship found for operations for abdominal aortic aneurysms and congenital cardiac defects and the lack of such a relationship for coronary artery bypass grafting. This observation may be largely explained by the quality improvement program in New York State for bypass operations since 1989. If so, these results have important implications for expanding the scope of quality improvement efforts in New York State.