[First French-speaking days of users of decision support system in clinical pharmacy: Feedback and perspectives]

Clinical decision support systems (CDSS) are tools that have been used for several years by clinical pharmacy teams to support pharmaceutical analysis, with a perspective of contributing to the quality of care in collaboration with the other health care team members. These tools require both technical, logistical and human resources. The growing use of these systems in different establishments in France and in Europe gave birth to the idea of meeting to share our experiences. The days organized in Lille in September 2021 aimed at proposing a time of exchange and reflection on the use of these CDSS in clinical pharmacy. A first session was devoted to feedback from each establishment. These tools are essentially used to optimize pharmaceutical analysis and to secure patient medication management. This session outlined the clear advantages and common limitations of these CDSS. Two research projects were also presented to put the use of these tools into perspective. The second session of these days, in the form of workshops, addressed 4 themes that surround the implementation of CDSS: their usability, the legal aspect, the creation of rules and their possible valorization. Common problems were raised, the resolution of which requires close collaboration. This is a first step proposing a beginning of harmonization and sharing that should be deepened in order not to lose the dynamics created between the different centers. This event ended with the proposal to set up two working groups around these systems: the creation and structuring of rules for the detection of risk situations and the common valorization of the work.

Monocyte count-to-high-density lipoprotein-cholesterol ratio is associated with abdominal aortic aneurysm size

AIM

To determine the association of monocyte count-to-high-density lipoprotein (HDL)-cholesterol ratio, a recently emerged inflammatory marker, with abdominal aortic aneurysm (AAA) size.

PATIENTS & METHODS

A total of 120 asymptomatic AAA subjects (99 male, mean age: 67.1 ± 10.2 years) were enrolled into the study. All data were compared between patients with low and high admission monocyte/HDL ratio. Multivariate linear regression analysis was performed to study the relationship between different variables and AAA size.

RESULTS

Compared to patients with below-median monocyte/HDL ratio, aneurysm diameter was significantly higher in above-median monocyte/HDL ratio group (54.3 ± 10.6 mm vs 62.0 ± 12.4 mm, p < 0.001, respectively). Hypertension, coronary artery disease, monocyte/HDL ratio and C-reactive protein were independently associated with AAA diameter.

CONCLUSION

Monocyte/HDL ratio is independently associated with AAA size.

Comparison of cutaneous nerve injury and vessel disruption complications following saphenous vein stripping using big or small olive heads

Objective:

To compare the nerve injury and vessel disruption complicaitons in patients undergoing saphenous vein stripping using olive heads of different sizes.

Methods:

Big olive heads were used in group A (n=50) and small olive heads were used in group B (n=50) from the ankle to the groin; in group C (n=50), the vein was stripped in two sections; in an upward fashion by stripping the distal portion from the ankle to the level of the knee using small olive heads and by stripping the proximal portion from the knee to the level of the groin using big olive heads.

Results:

Six months after the operation, nerve injury symptoms were identified in 26%, 4%, 6% of patients in groups A, B, and C respectively. Vessel disruption occurred 2% in group A, 32% in group B, and 4% in group C. Both vessel disruption and nerve injury complications of group C were significantly lower than group A and B (p<0.001).

Conclusion:

Saphenous stripping using big olive heads for the proximal portion from the groin down to the level of the knee and using small olive heads for the distal portion from the knee to the level of the ankle is the alternative method which results in minimal nerve injury and vessel disruption.

New Cutting Method to Aid Performance of Graft-to-Graft Aortic Anastomosis

In graft-replacement surgery of the ascending aorta and aortic arch, 2 separate grafts are frequently needed in order to construct a more physiologically configured aorta. We describe a new cutting method for accurate performance of graft-to-graft anastomosis.

Effect of Left Atrial Reduction on Restoration and Maintenance of Sinus Rhythm in Patients Undergoing Mitral Valve Replacement: A Pilot Study

Background This pilot study aimed to evaluate the effectiveness of posterior left atrial wall plication (T-plasty) in patients with persistent atrial fibrillation (AF) (> 7 days) undergoing mitral valve surgery. Materials and Methods A total of 60 patients who were scheduled for mitral valve replacement were randomly allocated into two groups: one would receive (Group 1; n = 32, mean age; 49.37 ± 9.00) and one would not receive (Group 2; n = 28; mean age 48.64 ± 8.6) left atrial size reduction using T-plasty technique. Patients with a clear indication for combined procedures other than tricuspid valve disease, aortic valve disease, and coronary artery stenosis were not included. Follow-up was performed at 6th, 12th, and 18th months after the operation. Results After the operation, 21 patients (65.6%) in Group 1 and 13 patients (46.4%) in Group 2 regained sinus rhythm (p = 0.13). Mortality did not occur. AF recurrence rates were not significantly different between the groups in three follow-ups. Restoration of sinus rhythm was significantly more common in Group 1 patients than in Group 2 patients during follow-up. Patients in Group 1 had lower left atrial volume indexes than those in Group 2 at the 6th and 12th months, whereas the difference at the 18th month was at the limit of significance. Conclusion We achieved satisfactory results using the T-plasty technique for left atrial size reduction in terms of mid-term restoration and preservation of normal sinus rhythm in patients undergoing mitral valve surgery. Further study may be justified to reveal the prognostic importance of the technique described herein.

A novel suture technique for distal aorta-graft anastomosis in aortic aneurysm repair surgery: diagonal basting stitch

We describe a novel suture technique of distal anastomosis between the graft and the aorta in ascending aortic aneurysm repair surgery. In this technique, the aortic graft is positioned inside the distal aortic lumen with an overlapping segment and circumferential or back wall part only diagonal basting stitches are performed without use of Teflon pledgets, strips, or bioadhesives. This new technique establishes a secure anastomosis line, shortens anastomosis time, and avoids the use of foreign materials.

A comparison of the effects of ketamine and remifentanil on renal functions in coronary artery bypass graft surgery

We have investigated the effects of ketamine-based and remifentanil-based anesthetic protocol on perioperative serum cystatin-C levels, and creatinine and/or cystatin-C-based eGFR equations in terms of acute kidney injury in coronary artery bypass graft (CABG) surgery. Using a simple randomization method (coin tossing), patients were divided into the two groups and not-blinded to the anesthetist. Remifentanil-midazolam-propofol or ketamine-midazolam-propofol-based anesthetic regimen was chosen. Different eGFR formulas using creatinine (MDRD, CKD-EPI, Cockrauft Gault); cystatin-C (eGFR1, eGFR2) or a combination of creatinine and cystatin-C (eGFR 3) were used to calculate estimated glomerular filtration rates (eGFRs). High-sensitive troponin T was used to determine if ketamine use in coronary surgery contributed to myocardial cell damage. Thirty-seven patients were included in the study (remifentanil group = 19, ketamine Group = 18). Urea, creatinine, cystatin-C levels were comparable between the groups in all the measurement times and also postoperative day 2 samples showed statistically higher results compared to baseline (p < 0.001). Effects of ketamine and remifentanil on renal functions were found similar. Creatinine and cystatin-C-based eGFR equations resulted similar in our study. Reversible stage 1 acute kidney injury (AKI) was observed on postoperative day 2 in seven patients from the remifentanil group and six patients from the ketamine group. Hs-troponin T was found to be higher in postoperative day 1 samples; there were no significant difference between the groups. Our results indicated that patients who have normal renal functions undergoing on-pump coronary bypass surgery, effects of ketamine and remifentanil on renal functions in terms of AKI were found to be similar.

Transventricular mitral valve repair in patients with acute forms of ischemic mitral regurgitation

Transventricular mitral valve surgery combined with left ventricular restoration avoids atriotomy and provides a larger operative field. We describe a series of 5 patients in whom we performed transventricular mitral valve repair by various techniques, such as band annuloplasty, papillary muscle reattachment, chordal cutting, and edge-to-edge repair. The more acute forms of ischemic mitral regurgitation, as found in our patients, can coexist with post-myocardial infarction contained rupture or post-myocardial infarction ventricular septal rupture. Because these patients already have an indication for ventriculotomy, concomitant transventricular repair of the mitral valve can render a separate atriotomy unnecessary and thereby shorten the duration of cardiopulmonary bypass. Moreover, in patients with acute presentations, the absence of atrial dilation (this last associated with chronic cases) might make transventricular repair a better choice than the more difficult atrial approach.

Papillary muscle repositioning as a subvalvular apparatus preservation technique in mitral stenosis patients with normal left ventricular systolic function

Subvalvular apparatus preservation is an important concept in mitral valve replacement (MVR) surgery that is performed to remedy mitral regurgitation. In this study, we sought to determine the effects of papillary muscle repositioning (PMR) on clinical outcomes and echocardiographic left ventricular function in rheumatic mitral stenosis patients who had normal left ventricular systolic function. We prospectively assigned 115 patients who were scheduled for MVR surgery with mechanical prosthesis to either PMR or MVR-only groups. Functional class and echocardiographic variables were evaluated at baseline and at early and late postoperative follow-up examinations. All values were compared between the 2 groups. The PMR group consisted of 48 patients and the MVR-only group of 67 patients. The 2 groups' baseline characteristics and surgery-related factors (including perioperative mortality) were similar. During the 18-month follow-up, all echocardiographic variables showed a consistent improvement in the PMR group; the mean left ventricular ejection fraction deteriorated significantly in the MVR-only group. Comparison during follow-up of the magnitude of longitudinal changes revealed that decreases in left ventricular end-diastolic and end-systolic diameters and in left ventricular sphericity indices, and increases in left ventricular ejection fractions, were significantly higher in the PMR group than in the MVR-only group. This study suggests that, in patients with rheumatic mitral stenosis and preserved left ventricular systolic function, the addition of papillary muscle repositioning to valve replacement with a mechanical prosthesis improves left ventricular dimensions, ejection fraction, and sphericity index at the 18-month follow-up with no substantial undesirable effect on the surgery-related factors.

A novel modified Robicsek technique for sternal closure: “Double-check”

A median sternotomy is the most common approach for cardiac and great vessel surgery. After a median sternotomy, healing complications such as instability, nonunion, and infection, are rare but devastating. Predisposing factors for sternal complications are old age, diabetes, steroid treatment, postmenopause state, obesity, reoperation, and the use of bilateral internal mammary arteries. Patients with sternal dehiscence frequently require reoperation to maintain optimum sternal stability. The technique chosen for sternal closure must provide excellent sternal approximation. We describe a modified Robicsek procedure reinforced with figure-of-8 sternal wires. We named this technique “double-check”.

Efficacy of iloprost and montelukast combination on spinal cord ischemia/reperfusion injury in a rat model

Background

The thoracic or thoracoabdominal aortic aneurysm surgery may cause spinal cord ischemia because of aortic cross-clamping and may result in severe postoperative complications caused by spinal cord injury. Ischemia/reperfusion injury may directly or indirectly be responsible for these complications. In this study we sought to determine whether combination of iloprost and montelukast can reduce the ischemia/reperfusion injury of spinal cord in a rat model.

Methods

Medulla spinalis tissue concentrations of interleukin-6 (IL-6), myeloperoxidase (MPO) and heat shock protein 70 (HSP-70) were determined in 3 groups of Spraque Dawley rats: control group (operation with cross clamping and intraperitoneal administration of 0.9% saline, n = 7), sham group (operation without cross clamping, n = 7), and study group (operation with cross-clamping and intraperitoneal administration of iloprost (25 ng/kg) and montelukast (1 mg/kg), n = 7). The abdominal aorta was clamped for 45 minutes, with a proximal (just below the left renal artery) and a distal (just above the aortic bifurcation) clip in control and study groups. Hindlimb motor functions were evaluated at 6, 12, 24, and 48 hours using the Motor Deficit Index score. All rats were sacrificed 48 hours after the procedure and spinal cord tissue levels of myeloperoxidase, interleukin-6, and heat shock protein (HSP-70) were evaluated as markers of oxidative stress and inflammation. Histopathological analyses of spinal cord were also performed.

Results

The tissue level of HSP-70 was found to be similar among the 3 groups, however, MPO was highest and IL-6 receptor level was lowest in the control group (p = 0.007 and p = 0.005; respectively). In histopathological examination, there was no significant difference among the groups with respect to the neuronal cell degeneration, edema, or inflammation, but vascular congestion was found to be significantly more prominent in the control group than in the sham or in the study group (p = 0.05). Motor deficit index scores at 24 and 48 hours after ischemia were significantly lower in the study group than in the control group.

Conclusion

This study suggests that combined use of iloprost and montelukast may reduce ischemic damage in transient spinal cord ischemia and may provide better neurological outcome.

Effect of heparin on neuroprotection against spinal cord ischemia and reperfusion in rats

BACKGROUND

Paraplegia due to ischemia/reperfusion (I/R) injury of the spinal cord is a devastating and undesired complication of thoraco-abdominal aortic surgery. Unidentified clots cause a variety of thromboembolic events and deteriorate the severity of ischemia. We investigated the effect of the degree of anticoagulation on spinal cord I/R injury and whether heparin is protective against I/R injury beside its anticoagulant properties.

MATERIALS AND METHODS

Twenty-eight rats were randomly assigned to four groups (n=7 per group) as G1 (no aortic occlusion and heparin administration), G2 (45 min aortic occlusion; no heparin administration), G3 (45 min aortic occlusion; 400 IU/kg heparin to keep activated clotting time (ACT) level around 200 sec), and G4 (45 min aortic occlusion; 800 IU/kg heparin to keep ACT level around 600 sec). After neurologic evaluation at the 48th hour of reperfusion, lumbar spinal cords were removed for histopathologic evaluation and immunohistochemical staining for HSP70 (heat shock protein 70), interleukin-6 and myeloperoxidase (MPO).

RESULTS

The Motor Deficit Index (MDI) scores were lowest in G1 group (p < 0.05) and the MDI scores of G3 and G4 were significantly lower than G2 group (p < 0.05). The neuronal degeneration in G3 was significantly lower than the other groups, respectively (p = 0.03). Histopathological evaluation showed no significant intergroup differences in terms of the degree of edema and inflammatory response. There was no statistically significant difference found among the groups in terms of HSP70 staining, IL-6 staining or the degree of MPO staining.

CONCLUSIONS

Protection of spinal cord from I/R injury requires a multimodal management. We should not miss out the importance of adequate anticoagulation in thoraco-abdominal surgical procedures. Furthermore, the recently discovered anti-inflammatory property of glycosaminoglycans, including heparin, deserves to be investigated.

Single-stage repair of adult aortic coarctation and concomitant coronary artery disease: an unusual surgical approach through median sternotomy

Surgical repair of postductal aortic coarctation associated with severe coronary artery disease is in most cases a difficult decision to make. As staged procedures are associated with a higher rate of morbidity and mortality, simultaneous operative management of both pathologies is desirable. We describe a case of a 51-year-old man who was referred to our department for surgical treatment of postductal aortic coarctation and concomitant coronary artery disease, which we managed with single-stage surgery through median sternotomy.

Protective effect of heparin in the end organ ischemia/reperfusion injury of the lungs and heart

BACKGROUND

Ischemia/reperfusion (I/R) injury is harmful to the cardiovascular system and is responsible for the inflammatory response and multiple organ dysfunctions. In this study we investigated the effect of activated clotting time level on the aortic cross-clamping triggers a systemic inflammatory response and it effects to lungs and heart.

METHODS

End organ concentrations of interleukin-6 (IL-6), myeloperoxidase (MPO) and heat shock protein 70 (HSP-70) were determined in four groups of Spraque Dawley rats: ischemic control (operation with cross clamping received IP of 0.9% saline at 2 ml/kg n=7) Sham (operation without cross clamping, n=7), heparin (ACT level about 200), High dose heparin (ACT level up to 600) The infrarenal aorta was clamped for 45 minutes by a mini cross clamp approximately 1cm below the renal artery and 1cm iliac bifurcation in all groups without sham group. Heparin was given intraperitoneal (IP) before the procedure. All rats were sacrificed 48 h later. In a second experiment, the effects of I/R on remote organs (lungs and heart) were harvested for analysis. We evaluated tissue levels of myeloperoxidase, interleukin-6, and heat shock protein (HSP-70) were analyzed as markers oxidative stress and inflammation. Histological analyses of the organs were performed.

RESULTS

The lungs paranchymal MPO and HSP-70 levels significantly decreased (p<0.05), but IL-6 level was not significant (p>0.05) in heparinized and high dose heparinized groups when compared to ischemic control group. Histopathological evaluation as edema, cell degeneration, inflammation statistically significantly decreased in both group heparinized and high dose heparinized compared with ischemic control group (p<0.05). The heart paranchymal MPO levels significantly decreased in heparinized and high dose heparinized groups when compared to ischemic control group (p=0.023). IL-6, HSP-70 levels were not significant heparinized and high dose heparinized groups when compared to ischemic control group (p=0.0489, p=0.0143). Histopathological evaluation as degeneration statistically significantly decreased in both group heparinized and High dose heparinized compared with ischemic control group (p=0.005).

CONCLUSION

Heparin decreased remote organs injury on the lung and heart after ischemia/reperfusion of infra-renal section of the body in the rat model. So, we should be balance to act level for avoid to I/R injury per operative and early post operative period as providing ACT level nearly 200.

Novel longitudinal plate-fixation technique after gross resection of the sternum

Herein, we describe a plate-fixation technique as an alternative method to close a fragile or fractured sternum. A 69-year-old obese woman with diabetes mellitus and chronic obstructive pulmonary disease underwent coronary artery bypass grafting. One week postoperatively, sternal instability was detected, and traditional rewiring was performed. A week later, because of multiple sternal fractures, we performed sternal resection, with use of longitudinally affixed titanium plates and figure-8 steel wires for the anterior chest wall. The procedure was uneventful, and, on short-term follow-up, the anterior chest wall was stable. This longitudinal plate-fixation technique can be tailored to each patient. We think that the technique is safe, effective, economical, and easy to implement, and it is readily reproducible. To evaluate any associated risks, long-term follow-up in additional patients is warranted.

Pulmonary endarterectomy: with use of moderate hypothermia and antegrade cerebral perfusion without circulatory arrest

Pulmonary endarterectomy is the treatment of choice in suitable patients who have chronic thromboembolic pulmonary hypertension. The most common surgical technique involves the use of deep hypothermic circulatory arrest. Herein, we describe a modified aortic clamping technique with selective antegrade cerebral perfusion, performed with moderate hypothermia but without circulatory arrest. This technique avoids the adverse effects of deep hypothermic circulatory arrest and also establishes a bloodless surgical field. We achieved good surgical results and acceptable long-term outcomes in 3 patients with use of this technique, which we recommend as a feasible alternative to the standard operative practice.

Single-stage aortic valve-sparing root replacement and extra-anatomic bypass for aortic arch interruption in an adult

We describe the treatment of an extremely rare case of interrupted aortic arch, annuloaortic ectasia, and aortic regurgitation in a 34-year-old man who presented with dyspnea and palpitation. We performed a single-stage operation involving aortic root reconstruction and valve repair with concomitant extra-anatomic bypass from the ascending to the descending aorta with a Dacron tube graft. The patient made a full recovery. To the best of our knowledge, this is the first such report in the English medical literature.

Chylomediastinum following mitral valve replacement

Chylomediastinum is a rare but potentially serious complication. There is as yet no definitive treatment. We present an exceptional case of chylomediastinum due to mitral valve replacement. The patient was successfully treated using a conservative approach with total parenteral nutrition, nothing by mouth, and mediastinal tube drainage.

A modified approach: chordal transfer together with shortening

We describe a simple method to repair anterior mitral leaflets with elongated chordae, using chordal shortening and transfer techniques on the same segment. With this method, optimal elongated chordae shortening is determined easily, and shortened chordae are supported by the transferred chordae.

The operative management of a displaced atrial septal occluder

We present a case of a displaced atrial septal defect (ASD) occluder in the left ventricle. We successfully adapted a strategy to remove the device through a single right atrial incision which permitted retrieval of the occluder and the closure of the ASD.

Primary cardiac myxomas: clinical experience and surgical results in 67 patients

BACKGROUND

Primary cardiac tumors are rarely seen and have an incidence of 0.3% of all open-cardiac operations. Among those, myxoma is the most common cardiac tumor. There are only a few reports of such tumors from Turkey.

METHODS AND RESULTS

We report our experience with 67 patients with primary cardiac myxoma operated on at our institute between December 1990 and October 2006. The study group comprised 22.38% males and 77.61% females with a mean age of 46.29 (+/-18.29) years. The predominant symptoms were dyspnea and palpitation. In addition, 3 patients presented with peripheral embolism with impending limb ischemia that necessitated emergency embolectomy. Echocardiography was generally enough for the demonstration of the myxomas. Two sporadic myxomas (%2.98) and one familial myxomas (1.49%) presented with recurrence. There were three (4.47%) hospital mortalities. Two patients (2.27%), with preoperative decompensation, died after tumor resection, from progressive low cardiac output. One patient, with preoperative massive pulmonary embolus, died two days after operation, from right ventricle insufficient.

CONCLUSION

In conclusion, we herein summarized surgical results with primary cardiac myxomas. Surgical excision of primary cardiac myxomas tends to show excellent results after surgical excision.