What a Waste! The Impact of Unused Surgical Supplies in Hand Surgery and How We Can Improve

BACKGROUND

The US health care system is the second largest contributor of trash. Approximately 20% to 70% of waste is produced by operating rooms, and very few of this waste is recycled. The purpose of this study is to quantify the opened but unused disposable supplies and generate strategies to reduce disposable waste.

METHODS

A single-center prospective study to evaluate the cost of opened but unused single-use operating room supplies was completed by counting the number of wasted disposable products at the end of hand surgery cases. We used χ2 test, t test, Wilcoxon rank-sum test, and simple linear regression to assess the associations between patient and case variables and the total cost of wasted items. Environmentally Extended Input Output Life Cycle Assessment methods were used to convert the dollar spent to kilograms of carbon dioxide equivalent (CO2-e), a measure of greenhouse gas emissions.

RESULTS

Surgical and dressing items that were disposed of and not used during each case were recorded. We included 85 consecutive cases in the analysis from a single surgeon's practice. Higher cost from wasted items was associated with shorter operative time (P = .010). On average, 11.5 items were wasted per case (SD: 3.6 items), with a total of 981 items wasted over the 85 cases in the study period. Surgical sponges and blades were 2 of the most unused items. Wasted items amounted to a total of $2193.5 and 441 kg of CO2-e during the study period.

CONCLUSIONS

This study highlights the excessive waste of unused disposable products during hand surgery cases and identifies ways of improvement.

Hand Function Following Simulated Fusion of Thumb Metacarpophalangeal and Interphalangeal Joints

Background: There is poor understanding regarding functional limitation of thumb strength and dexterity following thumb metacarpophalangeal (MCP) and interphalangeal (IP) arthrodesis. The purpose of this investigation was to quantitatively evaluate the functional limitations of MCP and IP joint fusion using an orthosis to simulate fusion. Methods: Thirty-two healthy volunteers underwent simulated MCP and IP thumb arthrodesis using custom-molded orthoses. Each volunteer was independently assessed for hand and thumb function using the Jebsen-Taylor Hand Function test, lateral pinch strength, tip pinch strength, and Grooved Pegboard test. Comparisons between the 3 groups in all functional tests were carried out. Results: The mean lateral pinch strength was significantly greater in the unsplinted group (8.3 kg) compared with the MCP- (6.3 kg) and IP-splinted (5.7 kg) groups. Mean tip pinch strength was also significantly higher in the unsplinted group than in MCP- and IP-splinted thumbs (4.6 kg vs 4.1 and 3.9 kg). There was no difference in the Jebsen-Taylor or Grooved Pegboard test between the 3 groups. Conclusion: Our study suggests that with a fused MCP joint the lateral and tip pinch strength will decrease by 24% and 10%, respectively, compared with a healthy nonsplinted thumb. A fused IP joint will decrease lateral and tip pinch by 31% and 16%, respectively. This information does not take into account an arthritic thumb. We found that the Jebsen-Taylor test and Grooved Pegboard test were not affected by simulated thumb MCP and IP fusion.

Association between meteorological variables and semen quality: a retrospective study

Spermatogenesis is a temperature-dependent process, and high summer temperatures have been linked to lower sperm concentration and count. However, reports describing the association between other meteorological variables and semen quality are scarce. This study evaluated the association between semen quality and temperature, humidity, pressure, apparent temperature (AT), temperature-humidity index (THI), simplified wet-bulb global temperature (sWBGT), and sunshine duration. Semen samples were obtained at the Laboratorio de Andrología y Reproducción (LAR, Argentina), from men undergoing routine andrology examination (n=11657) and computer-assisted sperm analysis (n=4705) following WHO 2010 criteria. Meteorological variables readings were obtained from the Sistema Meteorológico Nacional. Sperm quality parameters were negatively affected in summer when compared to winter. Additionally, there was a significant decrease in sperm kinematics between winter and spring. Branch and bound variable selection followed by multiple regression analysis revealed a significant association between semen quality and meteorological variables. Specifically, changes in sunshine duration and humidity reinforced the prognosis of semen quality. Highest/lowest sunshine duration and humidity quantiles resulted in decreased sperm concentration, count, motility, vitality and membrane competence, nuclear maturity, and sperm kinematics associated to highest sunshine duration and lowest humidity. Findings from this report highlight the relevance of environmental studies for predicting alterations in male reproductive health associated to variations in meteorological variables, especially considering the current climate changes around the planet due to global warming and its consequences for human health.

Identification of early stage recurrence endometrial cancer biomarkers using bioinformatics tools

Endometrial cancer (EC) is the sixth most common cancer in women worldwide. Early diagnosis is critical in recurrent EC management. The present study aimed to identify biomarkers of EC early recurrence using a workflow that combined text and data mining databases (DisGeNET, Gene Expression Omnibus), a prioritization algorithm to select a set of putative candidates (ToppGene), protein-protein interaction network analyses (Search Tool for the Retrieval of Interacting Genes, cytoHubba), association analysis of selected genes with clinicopathological parameters, and survival analysis (Kaplan-Meier and Cox proportional hazard ratio analyses) using a The Cancer Genome Atlas cohort. A total of 10 genes were identified, among which the targeting protein for Xklp2 (TPX2) was the most promising independent prognostic biomarker in stage I EC. TPX2 expression (mRNA and protein) was higher (P<0.0001 and P<0.001, respectively) in ETS variant transcription factor 5-overexpressing Hec1a and Ishikawa cells, a previously reported cell model of aggressive stage I EC. In EC biopsies, TPX2 mRNA expression levels were higher (P<0.05) in high grade tumors (grade 3) compared with grade 1–2 tumors (P<0.05), in tumors with deep myometrial invasion (>50% compared with <50%; P<0.01), and in intermediate-high recurrence risk tumors compared with low-risk tumors (P<0.05). Further validation studies in larger and independent EC cohorts will contribute to confirm the prognostic value of TPX2.

Pressure ulcer prevalence and perceptions on prevention: a hospital-wide survey of health professionals

OBJECTIVE

Hospital-acquired pressure ulcers (HAPUs) remain a problem despite numerous prevention initiatives. To understand why, it is necessary to know health professionals' perceptions regarding the importance of prevention, and the usability of current initiatives. We hypothesised that positive perceptions of existing initiatives would not be correlated with low HAPU prevalence, and that health professionals would perceive the initiatives to have a low usability.

METHOD

A two-part, online survey was developed and distributed electronically to nurses, in-training physicians and attending physicians, across all inpatient and perioperative departments of an academic hospital. Part one of the survey was the Agency for Healthcare Research and Quality (AHRQ) Staff Attitude Scale on beliefs regarding PU prevention; part two was additional questions on the usability of existing preventative initiatives. The results of the survey were compared with quarterly HAPU prevalence data by hospital unit.

RESULTS

In total, 839 health professionals completed the survey (579 nurses, 131 residents, 119 attending physicians). The mean score for the AHRQ survey was 42.5 (≥40 denoting positive perceptions). There was a moderate correlation between AHRQ scores and prevalence of HAPUs (r=-0.60, p=0.402). For usability, repositioning was felt to be the most effective intervention (mean: 4.54, standard deviation (SD): 0.64), while educational posters were felt to be the least effective (mean: 3.31, SD: 0.99). Respondents generally rated satisfaction much lower, with no single initiative significantly better than the others (range: 3.21-3.79). Perceived effectiveness and satisfaction were all positively correlated.

CONCLUSION

High HAPU prevalence, despite position perceptions, suggests that prevention methods are not as effective as thought, or they are not being used as widely as they should. Further research should take advantage of positive attitudes by prospectively investigating the usability of novel interventions.

Impact of age, clinical conditions, and lifestyle on routine semen parameters and sperm kinematics

OBJECTIVE

To assess the impact of aging on routine semen and computer-assisted sperm analysis (CASA) motility parameters according to the current World Health Organization guidelines; and to evaluate the effect of obesity and lifestyle (alcohol consumption, cigarette smoking) in older men's semen.

DESIGN

Blind cross-sectional study.

SETTING

Research laboratory and andrology and reproduction laboratory.

PATIENT(S)

A population of 11,706 men.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Semen analysis: routine (semen volume, sperm concentration and count, motility, vitality, morphology, hypo-osmotic swelling test, round and peroxidase-positive cell concentration) and CASA (straight-line velocity, curvilinear velocity, average path velocity, linearity, straightness, beat cross frequency, wobble, amplitude of lateral head displacement, and mean angular displacement) parameters; and body mass index.

RESULT(S)

A negative correlation was found between age and routine semen parameters: volume, sperm count, motility, vitality, total motile spermatozoa and normal-motile spermatozoa, round cell concentration, and hypo-osmotic swelling test values. Several CASA variables (straight-line velocity, curvilinear velocity, average path velocity, beat cross frequency, amplitude of lateral head displacement, and mean angular displacement) were also negatively affected. Using 40 years as a cut-off value, significant differences in most parameters correlated to age. In a selected subpopulation of men unexposed to known fertility-compromising factors, the same evaluations were performed, finding some parameters still decreased. Although obesity exerted a significant deleterious effect on older patients' semen quality, alcohol consumption and cigarette smoking mildly affected it.

CONCLUSION(S)

Male aging, with the contribution of unhealthy conditions, are paramount effectors of sperm quality deterioration.

Utilizing a Global Cancer Center Network for Tobacco Control: Baseline Survey of MD Anderson´s Global Academic Program´s Sister Institution

Background: Globally, tobacco can be attributed to more than 7 million deaths each year. To address this potentially avoidable mortality, The University of Texas MD Anderson Cancer Center has engaged its Global Academic Program´s (GAP) sister institutions (SI) by conducting an inaugural tobacco control assessment survey. A similar survey was done with our University of Texas academic and health science center affiliates that led to improved adoption of tobacco control policies as well as prevention and cessation services on all campuses. The baseline data collected will serve as a mechanism to develop a tobacco prevention and control strategy within a global cancer center network. Aim: To assess SI laws and policies regarding tobacco use, existing screening and cessation services. Strategy/Tactics: Qualtrics was used to administer a 27-item survey to our GAP SI from April-October 2017. Survey questions focused on key areas of tobacco prevention and control: policy, tobacco use screening, and cessation services. A survey link was emailed to 34 institutions in 23 countries. Program/Policy process: Survey GAP SI to determine current tobacco prevention and control measures being implemented. Convene GAP SI in May 2018 to share tobacco control best practices across the network and identify resources and supports to strengthen tobacco control efforts at each institution. Build collaborations aimed at progressive actions in tobacco control policies, educational programs and cessation services culturally appropriate to the needs and resources of the GAP network. Outcomes: Of the 34 GAP SI, 26 responded to the survey (76% response rate). Key findings among the 26 responding institutions: policy - 96% are located in cities with laws regulating the sale and/or use of tobacco products by minors and 77% of the cities have laws regulating the use of tobacco in the workplace; 42% of the campuses have designated smoking areas; tobacco use screening - 65% screen for and document patients´ tobacco status, however only 27% screen “all the time”; cessation services - 19% offer telephone counseling as a cessation service; 38% offer cessation services to the community; 46% offer cessation services to employees. What was learned: The baseline assessment identified areas of institutional needs: cessation services and campus policies. Further discussion with the SI will help engage them in further efforts to address gaps in tobacco control. Collectively, we aim to develop action steps to collaborate and enhance existing services by creating a global platform in which tobacco control best practices and resources can be shared.

Dorsal and Volar Surgical Approaches to the Metacarpophalangeal Joint: A Comparative Anatomic Study

BACKGROUND

We compared 3 surgical approaches to the MP joint: a dorsal extensor tendon-splitting approach, a dorsal extensor tendon-reflecting parasagittal approach, and the volar A1 pulley approach. We quantitatively compared each of these approaches by measuring the amount of articular cartilage exposed on the base of the proximal phalanx. We hypothesize that visualization of the articular cartilage of the proximal phalangeal base is enhanced with the volar approach.

METHODS

The MP joints of the 32 available digits were randomly assigned to 1 of 3 surgical approaches: extensor tendon splitting (A), extensor tendon reflecting (B), or volar approach (C). After each approach, the visible articular surface of the base of the proximal phalanx was stained with methylene blue. The MP joints were then disarticulated, and the proximal phalanges were digitally mapped using a 3-dimensional digitizer. Three-dimensional computer software was used to analyze and calculate the dyed exposed surface area and total surface area of each specimen.

RESULTS

The mean % exposed joint surface area for the dorsal extensor splitting, dorsal extensor reflecting and volar approaches were 62%, 67% (over the dorsal side of the proximal phalanx) and 54% (over the volar side of the proximal phalanx), respectively. Multiple linear regression showed statistical significance for a smaller percentage of articular surface area exposed with the volar approach. However, this was not clinically significant. A significant association was found between location in the small finger and greater % exposed joint surface, compared to approaches in the index finger. In all volar approach specimens, the collateral insertion site was visible, but not in the dorsal approach specimens.

CONCLUSIONS

Knowledge of the limits of each exposure is essential for planning the most appropriate surgical approach. The A1 pulley approach provided greater access to the volar 50% of the joint and collateral ligament insertion without violating the extensor mechanism. The amount of joint surface visualized through all 3 approaches was not significantly different. However, based on the accessibility to the collateral ligament insertion site among three different approaches, we recommend the volar A1 pulley approach for treatment of avulsion fractures of the base of the proximal phalanx. For other injuries of the MP joint, including the intra-articular proximal phalanx base fractures, and metacarpal head fractures, the dorsal approaches are still indicated.

The Effect of Price on Surgeons' Choice of Implants: A Randomized Controlled Survey

PURPOSE

Surgical costs are under scrutiny and surgeons are being held increasingly responsible for cost containment. In some instances, implants are the largest component of total procedure cost, yet previous studies reveal that surgeons' knowledge of implant prices is poor. Our study aims to (1) understand drivers behind implant selection and (2) assess whether educating surgeons about implant costs affects implant selection.

METHODS

We surveyed 226 orthopedic surgeons across 6 continents. The survey presented 8 clinical cases of upper extremity fractures with history, radiographs, and implant options. Surgeons were randomized to receive either a version with each implant's average selling price ("price-aware" group), or a version without prices ("price-naïve" group). Surgeons selected a surgical implant and ranked factors affecting implant choice. Descriptive statistics and univariate, multivariable, and subgroup analyses were performed.

RESULTS

For cases offering implants within the same class (eg, volar locking plates), price-awareness reduced implant cost by 9% to 11%. When offered different models of distal radius volar locking plates, 25% of price-naïve surgeons selected the most expensive plate compared with only 7% of price-aware surgeons. For cases offering different classes of implants (eg, plate vs external fixator), there was no difference in implant choice between price-aware and price-naïve surgeons. Familiarity with the implant was the most common reason for choosing an implant in both groups (35% vs 46%). Price-aware surgeons were more likely to rank cost as a factor (29% vs 21%).

CONCLUSIONS

Price awareness significantly influences surgeons' choice of a specific model within the same implant class. Merely including prices with a list of implants leads surgeons to select less expensive implants. This implies that an untapped opportunity exists to reduce surgical expenditures simply by enhancing surgeons' cost awareness.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analyses I.

Systematic Review of the Surgical Treatment of Extremity Lymphedema

Background Although conservative management of lymphedema remains the first-line approach, surgery is effective in select patients. The purpose of this study was to review the literature and develop a treatment algorithm based on the highest quality lymphedema research. Methods A systematic literature review was performed to examine the surgical treatments for lymphedema. Studies were categorized into five groups describing excision, liposuction, lymphovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and combined/multiple approaches. Studies were scored for methodological quality using the methodological index for nonrandomized studies (MINORS) scoring system. Results A total of 69 articles met inclusion criteria and were assigned MINORS scores with a maximum score of 16 or 24 for noncomparative or comparative studies, respectively. The average MINORS scores using noncomparative criteria were 12.1 for excision, 13.2 for liposuction, 12.6 for LVA, 13.1 for VLNT, and 13.5 for combined/multiple approaches. Loss to follow-up was the most common cause of low scores. Thirty-nine studies scoring > 12/16 or > 19/24 were considered high quality. In studies measuring excess volume reduction, the mean reduction was 96.6% (95% confidence interval [CI]: 86.2-107%) for liposuction, 33.1% (95% CI: 14.4-51.9%) for LVA, and 26.4% (95% CI: - 7.98 to 60.8%) for VLNT. Included excision articles did not report excess volume reduction. Conclusion Although the overall quality of lymphedema literature is fair, the MINORS scoring system is an effective method to isolate high-quality studies. These studies were used to develop an evidence-based algorithm to guide clinical practice. Further studies with a particular focus on patient follow-up will improve the validity of lymphedema surgery research.

Does Lung Donation by Heart Donors Have an Impact on Survival in Heart Transplant Recipients?

Lung procurement is increasing during multiorgan recovery and substantially alters the explant process. This study evaluated whether lung donation by a heart donor affects survival in heart transplant recipients. Retrospective analysis of United Network for Organ Sharing (UNOS) adult heart transplantation data from 1998 to 2012 was performed. Lung donors (LDs) were defined as those having at least one lung procured and transplanted. Non-LDs had neither lung transplanted. Heart transplant recipients who had previous transplants, who had heterotopic transplants, who were waitlisted for other organs or who were temporarily delisted were excluded from the analysis. Kaplan-Meier survival analysis and Cox proportional hazards regression were performed. Of 23 590 heart transplant recipients meeting criteria during the study period, 8638 (36.6%) transplants were from LDs. Donors in the LD group had less history of cigarette use (15.5% vs. 29.5%, p < 0.001). On univariate analysis, LDs were associated with improved patient survival (p < 0.001). On multivariate analysis, LDs were not significantly associated with patient survival (adjusted hazard ratio 0.98, 95% confidence interval 0.94-1.03). Analysis of the UNOS registry suggested that donor pulmonary status and lung procurement had no detrimental effect on survival in heart transplant recipients, supporting the present practice of using donor lungs whenever possible.

Discrimination in the workplace, reported by people with major depressive disorder: a cross-sectional study in 35 countries

OBJECTIVE

Whereas employment has been shown to be beneficial for people with Major Depressive Disorder (MDD) across different cultures, employers' attitudes have been shown to be negative towards workers with MDD. This may form an important barrier to work participation. Today, little is known about how stigma and discrimination affect work participation of workers with MDD, especially from their own perspective. We aimed to assess, in a working age population including respondents with MDD from 35 countries: (1) if people with MDD anticipate and experience discrimination when trying to find or keep paid employment; (2) if participants in high, middle and lower developed countries differ in these respects; and (3) if discrimination experiences are related to actual employment status (ie, having a paid job or not).

METHOD

Participants in this cross-sectional study (N=834) had a diagnosis of MDD in the previous 12 months. They were interviewed using the Discrimination and Stigma Scale (DISC-12). Analysis of variance and generalised linear mixed models were used to analyse the data.

RESULTS

Overall, 62.5% had anticipated and/or experienced discrimination in the work setting. In very high developed countries, almost 60% of respondents had stopped themselves from applying for work, education or training because of anticipated discrimination. Having experienced workplace discrimination was independently related to unemployment.

CONCLUSIONS

Across different countries and cultures, people with MDD very frequently reported discrimination in the work setting. Effective interventions are needed to enhance work participation in people with MDD, focusing simultaneously on decreasing stigma in the work environment and on decreasing self-discrimination by empowering workers with MDD.

Bibliometric assessment of the contributions of literature on Chagas disease in Latin America and the Caribbean

Chagas disease, considered a parasitic neglected disease, is endemic in Latin America. Although, its mortality rate has decreased over time, it still represents a public health problem in the region. A bibliometric evaluation of the Latin American contributions on this disease was done. This study used SCI (1980-2013), MEDLINE/GOPUBMED (1802-2013), Scopus (1959-2013), SCIELO (2004-2013), and LILACS (1980-2013). Different study types have been characterized by years, origin city/country, journals and most productive authors, by country, cites and H-index. 2988 articles were retrieved from SCI (30.85% of total). Brazil was found to be the highest producer (31.22%), followed by Argentina (18.14%) and México (9.57%); the region received 47241 citations, 28.60% for Brazil (H-index=52), 18.26% of Argentina (Hindex= 43), 11.40% Bolivia (H-index=37). 4484 were retrieved from Scopus (30.20% of the total), 38.58% of which were from Brazil, 12.40% from Argentina and 8.90% from Mexico. From Medline, 6647 records were retrieved (45.58% Brazil). From SciELO, 917 articles (47.66% Brazil). From LILACS, 2165 articles (60.05% Brazil). Brazil has the highest output in the region. Despite advances in controlling Chagas disease, scientific production is low, particularly for regional bibliographic databases, which calls for more research on this disease.

Heart transplantation versus continuous-flow left ventricular assist device: comprehensive cost at 1 year

BACKGROUND

With health care reform firmly on the horizon, it is critical to understand the costs associated with new technologies such as continuous-flow left ventricular assist device (CF-LVAD) compared with well established treatments such as heart transplantation (HT). Scarce data exist describing the costs of these 2 therapies after 1 year of support.

METHODS AND RESULTS

The study population consisted of 20 consecutive subjects who underwent implantation of a CF-LVAD and 20 consecutive subjects who underwent HT and survived ≥1 year. Comprehensive cost calculation included all direct and indirect costs from day of operation through 365 days and were inflation adjusted to 2010 US dollars. Hospital charges were converted to costs with the use of hospital-specific cost-to-charge ratios and were analyzed by time segment as well as cost center. The total 1-year cost was higher in the CF-LVAD group, although this difference did not reach statistical significance ($369,519 [interquartile range [IQR] $321,020-$520,395] vs $329,648 [IQR $278,924-$395,456]; P = .242). In both groups, the index admission constituted >50% of the total 1-year cost and the major drivers of expense by cost center were organ/device acquisition, room and board, and professional fees.

CONCLUSIONS

Patients surviving to 1 year on CF-LVAD support accrued costs similar to those of HT recipients; however, the total cost, at more than one-third of a million dollars, remains high. Reduction in the postoperative length of stay offers an avenue for significant cost savings.

Intraoperative epicardial ultrasound probe for visualization of embedded coronary arteries: a novel approach

The identification of coronary anatomy at the time of cardiac revascularization can be problematic. Preoperative studies (ie, coronary angiography) can aid in the mapping of the coronary anatomy. However, there remain a select few patients with intramyocardial coronaries that provide challenges for surgical dissection during revascularization. Probing the visible portion of the coronary artery, intraoperative cine angiography, thermal angiography, and epicardial Doppler probes have been used to identify the coronary anatomy intraoperatively. Aggressive surgical maneuvers can result in damage and increased time on cardiopulmonary bypass. Previous studies have used epicardial echocardiography on patients undergoing off-pump coronary artery bypass grafting. We report 2 cases in patients undergoing cardiac revascularization on cardiopulmonary bypass where the use of a high-frequency epicardial ultrasound probe facilitated the identification of the embedded coronary arteries. We describe a technique of using antegrade and retrograde cardioplegia administration sequentially to locate the coronary arteries. Easy availability and familiar technology make the epicardial Doppler probe an attractive tool for the identification of embedded coronary arteries.

Right ventricular dysfunction following continuous flow left ventricular assist device placement in 51 patients: predicators and outcomes

BACKGROUND

Right ventricular (RV) dysfunction following implantation of a left ventricular assist device (LVAD) is a serious condition and is associated with increased mortality.

METHODS

The aim of the study is to investigate the significance of pre-existing RV dysfunction, tricuspid valve (TV) insufficiency, and the severity of septal deviation following LVAD implantation on RV dysfunction, as well as the outcome and short-term complications in 51 patients from June 2006 to August 2010. Student t test was used to compare the data and estimate the p value.

RESULTS

Mean age was 55.1 ± 13, with a male to female ratio of 3.25. The 30-day mortality was 13.7% (7/51 patients), and the overall mortality was 23.5% (12/51 patients). Meanwhile, 21 patients (21/51; 41.2%) have undergone orthotopic heart transplantation. The mean time of support was 314.5±235 days with a median of 240 days at the time of closing this study. Echocardiographic evaluation of RV function pre- and post-implantation of an LVAD demonstrated septal deviation towards the left ventricle in immediate postoperative phase, which correlated with acute RV dysfunction (p = 0.002). Preoperative RV dysfunction was a significant predictor of postoperative right heart dysfunction following implantation of an LVAD (p = 0.001).

CONCLUSION

Preoperative RV dysfunction is a predictor of RV failure in LVAD patients. The adjustment of septal deviation through gradual increase of the LVAD flow can prevent the acute RV dysfunction following LVAD placement.

Progenitor cells from the explanted heart generate immunocompatible myocardium within the transplanted donor heart

RATIONALE

Chronic rejection, accelerated coronary atherosclerosis, myocardial infarction, and ischemic heart failure determine the unfavorable evolution of the transplanted heart in humans.

OBJECTIVE

Here we tested whether the pathological manifestations of the transplanted heart can be corrected partly by a strategy that implements the use of cardiac progenitor cells from the recipient to repopulate the donor heart with immunocompatible cardiomyocytes and coronary vessels.

METHODS AND RESULTS

A large number of cardiomyocytes and coronary vessels were created in a rather short period of time from the delivery, engraftment, and differentiation of cardiac progenitor cells from the recipient. A proportion of newly formed cardiomyocytes acquired adult characteristics and was integrated structurally and functionally within the transplant. Similarly, the regenerated arteries, arterioles, and capillaries were operative and contributed to the oxygenation of the chimeric myocardium. Attenuation in the extent of acute damage by repopulating cardiomyocytes and vessels decreased significantly the magnitude of myocardial scarring preserving partly the integrity of the donor heart.

CONCLUSIONS

Our data suggest that tissue regeneration by differentiation of recipient cardiac progenitor cells restored a significant portion of the rejected donor myocardium. Ultimately, immunosuppressive therapy may be only partially required improving quality of life and lifespan of patients with cardiac transplantation.

Demonstration of left ventricular outflow tract eccentricity by real time 3D echocardiography: implications for the determination of aortic valve area

BACKGROUND

Determination of the left ventricular outflow tract cross-sectional area (ALVOT) is necessary for calculating aortic valve area (AVA) by echocardiography using the continuity equation (CE). In the commonly applied form of CE, pir(2) is used to estimate ALVOT utilizing the assumptions that LVOT is round and the parasternal long axis (PLAX) plane bisects LVOT. Imaging LVOT using real time 3D echocardiography (RT3DE) eliminates the need for these assumptions. We tested the hypothesis that LVOT is round based on a formula for eccentricity.

METHODS AND RESULTS

In 53 patients, 2D echocardiography (2DE) and RT3DE were acquired. ALVOT was calculated by 2DE using pir(2) (ALVOT-2D). Using RT3DE, ALVOT planimetry was performed immediately beneath the aortic valve (ALVOT-3Dplan). Eccentricity Index (EI) was calculated using the shortest and longest LVOT diameters. The long axis was measured to be larger by 0.53 cm +/- 0.36 (P < 0.005). The median EI was 0.20 (0.00-0.54), indicating that half the subjects had at least a 20% difference between the major and minor diameters. ALVOT-3Dplan was larger than ALVOT-2D (3.73 +/- 0.95 cm(2) vs. 3.18 +/- 0.73 cm(2); P < 0.001) by paired analysis. Using the equation of an ellipse (piab), ALVOT-3Dellip was 3.57 +/- 0.95 resulting in improved agreement with ALVOT-3Dplan.

CONCLUSIONS

In our small patient sample with normal aortic valves, we showed the LVOT shape is usually not round and frequently, elliptical. Incorrectly assuming a round LVOT underestimated the ALVOT-3Dplan and consequently the AVA by 15%. Investigating the LVOT in aortic stenosis is warranted to evaluate whether RT3DE may improve measurement of AVA.

Pulmonary complications after descending thoracic and thoracoabdominal aortic aneurysm repair: predictors, prevention, and treatment

BACKGROUND

Although recent advances in surgical techniques have improved outcomes of descending thoracic (DTA) and thoracoabdominal aortic aneurysm (TAAA) repair, significant mortality and morbidity still occur. The aim of the current retrospective study is to determine predictors of postoperative pulmonary complications and prolonged hospital stay.

METHODS

Two hundred nineteen patients (median age, 66 years; range, 18 to 88; 112 male) underwent DTA (n = 79 [36%; 23 elephant trunk completions]) or TAAA (n = 140 [64%; Crawford I (52%), II (10%), III (11%), IV (7%); 31 elephant trunk completions]) between June 2002 and June 2005. Forty-one patients presented with ruptured aneurysms. Left atrial-to-femoral bypass was utilized in 51% of the patients. Femorofemoral bypass and distal aortic perfusion were used in 41% of the patients, deep hypothermic circulatory arrest (DHCA) was used in 43 patients (mean duration: 31 +/- 9 minutes); 8% were done with clamp-and-sew technique.

RESULTS

Adverse outcomes were seen in 21 patients (9.5%); hospital death in 13 (5.9%), and stroke in 13 (5 of whom died; 5.9%). Sixty patients (27%) experienced respiratory complications with prolonged postoperative ventilation (longer than 48 hours); 24 required tracheostomy (11%). Independent predictors of pulmonary complications after DTA/TAAA were TAAA (p = 0.03), preoperative blood urea nitrogen greater than 24 mg/dL (p = 0.03) and rupture (p = 0.09). The median hospital stay was 11 days (interquartile range, 6 to 35). Independent predictors of length of hospital stay were preoperative blood urea nitrogen (p = 0.045), postoperative bleeding (p < 0.005), reintubation (p = 0.001), tracheostomy (p < 0.0005), and transfusion of platelets (p = 0.008).

CONCLUSIONS

This contemporary experience demonstrates that preoperative renal insufficiency and extensive aneurysm are important predictors of respiratory complications after aortic aneurysm surgery.

Assessment of Cerebral Oxygen Balance During Deep Hypothermic Circulatory Arrest by Continuous Jugular Bulb Venous Saturation and Near-Infrared Spectroscopy

OBJECTIVE

The purpose of this study was to compare jugular venous bulb saturation (SjvO(2)) and regional cerebral oximetry (rSO(2)) by near-infrared spectroscopy (NIRS) during procedures with deep hypothermic circulatory arrest (DHCA).

DESIGN

Prospective observational study.

SETTING

Academic hospital.

PARTICIPANTS

Patients undergoing aortic reconstructive surgery with DHCA from July 2001 to January 2005.

INTERVENTION

The authors examined cerebral oxygenation by continuous NIRS monitoring and by blood gas analysis of intermittently sampled jugular bulb blood (SjvO(2)). Data were obtained during various stages of the procedure in 29 patients. NIRS measurements were compared with SjvO(2).

MEASUREMENTS AND MAIN RESULTS

NIRS and SjvO(2) trends were similar. Overall, cerebral venous oxygen saturation obtained from NIRS was lower compared with SjvO(2) (p < 0.05), especially during periods of low temperature. The mean correlation between NIRS and SjvO(2) was 0.363, and the individual correlations varied from -0.11 to 0.91. The low mean correlation was because of a high degree of variability in the NIRS data between patients.

CONCLUSION

It was concluded that NIRS does not closely correlate with SjvO(2) in this patient population. Cerebral oximetry measured by NIRS could not replace jugular bulb saturation as an intraoperative marker of adequate metabolic suppression.

Early and late results of combined carotid endarterectomy and coronary artery bypass versus isolated coronary artery bypass

OBJECTIVE

Optimal management of patients with combined coronary and carotid artery disease remains controversial. This study analyzed the outcomes between simultaneous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) vs. isolated CABG.

METHODS

We reviewed the early and late follow-up data of 412 patients who underwent either combined CEA/CABG vs. CABG alone between August 1999 and October 2003. All patients undergoing CEA had at least 80% stenosis of one carotid artery. Data were obtained for pre-, intra-, and early postoperative variables. Late follow-up data (range 1.1 to 69.5 months postoperative, mean 42.4 months, median 42.7 months) included myocardial infarctions (MI), stroke and death. Differences between the two groups were investigated. Univariate and multivariate analysis were carried out to identify predictors of death, MI, and stroke in the entire group.

RESULTS

There were 27 patients (6.6%) in the CEA/CABG group and 385 patients in the CABG alone group. There was one patient (3.7%) in the CEA/CABG group who had a perioperative stroke versus six (1.6%) in the CABG group (P=0.38). There were no documented postoperative myocardial infarctions (MI) by EKG and CK-MB criteria in both groups. There were no deaths in the CEA/CABG group versus three in the CABG group (P=1.00). Within the follow-up period, strokes developed in 2 (7.4%) CEA/CABG patients and in 7 (2.3%) CABG patients (P=0.16). Three CEA/CABG patients (11.1%) developed MI versus 19 (6.1%) patients in the CABG group (P=0.40). There were 4 (14.8%) deaths in the CEA/CABG group versus 51 (13.4%) in the CABG group (P=0.77). Freedom from death, stroke, and myocardial infarction was not statistically different between the groups at 60 months (all P>0.05).

CONCLUSIONS

The addition of CEA to CABG did not increase short- and long-term morbidity and mortality compared to isolated CABG in our group of patients. Combined CEA/CABG can be performed safely in this high-risk group of patients. Prospective randomized study is needed to further substantiate these findings.

Improved outcome after repair of descending and thoracoabdominal aortic aneurysms using modern adjuncts

OBJECTIVES

To evaluate current strategies to decrease spinal cord and organ dysfunction in patients undergoing repair of descending and thoracoabdominal aneurysms.

METHODS

We reviewed 94 consecutive cases of descending and thoracoabdominal aortic aneurysm repairs to determine the impact of modern adjuncts on postoperative neurologic deficit and mortality. The adjuncts used in these patients included perioperative cerebrospinal fluid drainage, distal aortic perfusion, reattachment of critical intercostal vessels, permissive hypothermia and hypothermic circulatory arrest with antegrade cerebral perfusion. Between December 1999 and March 2005, 24/94 (26%) patients were operated on for thoracoabdominal aortic aneurysm type I, seven (7%) for type II, 25/94 (27%) for type III or type IV, and 38/94 (40%) for descending thoracic aneurysms. Perioperative parameters were collected for all patients, and analyzed retrospectively.

RESULTS

Twenty (21%) of the patients required hypothermic circulatory arrest for conduction of the operation. The postoperative rate of paraplegia was 3% (3/94). One patient developed temporary paraparesis. Overall operative mortality was 10% (9/94). This included 12/94 (13%) patients who underwent surgery emergently for ruptured or contained rupture of aortic aneurysm.

CONCLUSION

Use of perioperative cerebrospinal fluid drainage, distal aortic perfusion and permissive hypothermia result in a low incidence of spinal cord injury and a low operative mortality.

Cardiovascular effects of the methanol and dichloromethanol extracts from Mentha suaveolens Ehrh

Methanol and dichloromethanol extracts of the leaves and stems of Mentha suaveolens Ehrh. have been tested for their effects on resting arterial blood pressure, heart rate and noradrenaline induced hypertension. Both extracts administered by i.v. bolus to urethane anaesthetized normotensive rats reduced the mean arterial blood pressure and heart rate, while only the dichloromethanol extract prevented the noradrenaline induced hypertension.