The incidence and effect of resternotomy following cardiac surgery on morbidity and mortality: a 1-year national audit on behalf of the Association of Cardiothoracic Anaesthesia and Critical Care

Over 30,000 adult cardiac operations are carried out in the UK annually. A small number of these patients need to return to theatre in the first few days after the initial surgery, but the exact proportion is unknown. The majority of these resternotomies are for bleeding or cardiac tamponade. The Association of Cardiothoracic Anaesthesia and Critical Care carried out a 1-year national audit of resternotomy in 2018. Twenty-three of the 35 centres that were eligible participated. The overall resternotomy rate (95%CI) within the period of admission for the initial operation in these centres was 3.6% (3.37–3.85). The rate varied between centres from 0.69% to 7.6%. Of the 849 patients who required resternotomy, 127 subsequently died, giving a mortality rate (95%CI) of 15.0% (12.7–17.5). In patients who underwent resternotomy, the median (IQR [range]) length of stay on ICU was 5 (2–10 [0–335]) days, and time to tracheal extubation was 20 (12–48 [0–2880]) hours. A total of 89.3% of patients who underwent resternotomy were transfused red cells, with a median (IQR [range]) of 4 (2–7 [1–1144]) units of red blood cells. The rate (95%CI) of needing renal replacement therapy was 23.4% (20.6–26.5). This UK-wide audit has demonstrated that resternotomy after cardiac surgery is associated with prolonged intensive care stay, high rates of blood transfusion, renal replacement therapy and very high mortality. Further research into this area is required to try to improve patient care and outcomes in patients who require resternotomy in the first 24 h after cardiac surgery.     

Pediatric Hand Injuries Requiring Closed Reduction at a Tertiary Pediatric Care Center

Background: Hand fractures and dislocations are common injuries in the pediatric population. This study aims to characterize the pediatric hand injuries that required closed reduction and identify those that required multiple reduction attempts. Methods: A retrospective cohort study was carried out in patients younger than 18 years of age with hand fractures or dislocations who underwent closed reduction in the emergency department (ED). Patients who ultimately required surgical reduction and fixation were not included. Results: Of the 310 hand injuries identified, 148 (114 fractures and 34 dislocations) underwent closed reduction in the ED; 7.4% of those required repeat reduction. Hand injuries that most often required repeat reduction included metacarpophalangeal joint dislocations (20.0%) and proximal phalanx neck (16.7%), metacarpal shaft (15.4%), metacarpal neck (6.2%), and proximal phalanx base (5.6%) fractures. No modifiable risk factors predicting the need for repeat reduction were identified. Conclusions: Some pediatric hand injuries are more likely to require repeat closed reduction by a hand surgeon. This retrospective study is the first step toward quality improvement as it provides opportunities for further research into the factors contributing to reductions that are unsuccessful at the first attempt. Identification of these factors and implementation of quality improvement measures are necessary to ensure the effective treatment of all pediatric hand injuries.     

Pretransplant solid organ malignancy and organ transplant candidacy: A consensus expert opinion statement

Patients undergoing evaluation for solid organ transplantation (SOT) often have a history of malignancy. Although the cancer has been treated in these patients, the benefits of transplantation need to be balanced against the risk of tumor recurrence, especially in the setting of immunosuppression. Prior guidelines of when to transplant patients with a prior treated malignancy do not take in to account current staging, disease biology, or advances in cancer treatments. To develop contemporary recommendations, the American Society of Transplantation held a consensus workshop to perform a comprehensive review of current literature regarding cancer therapies, cancer stage-specific prognosis, the kinetics of cancer recurrence, and the limited data on the effects of immunosuppression on cancer-specific outcomes. This document contains prognosis based on contemporary treatment and transplant recommendations for breast, colorectal, anal, urological, gynecological, and nonsmall cell lung cancers. This conference and consensus documents aim to provide recommendations to assist in the evaluation of patients for SOT given a history of a pretransplant malignancy.     

Examination stress: changes in serum cholesterol, triglycerides and total lipids

Serum cholesterol, triglycerides and total lipids were estimated in twelve students exposed to varying degree of examination stress. Serum cholesterol and triglycerides exhibited a rise proportional to degree of examination stress whereas total lipids exhibited an initial rise followed by a fall. Values of all these parameters attained control level when the stress was over. The rise in serum cholesterol and triglycerides seems to be due to stress induced changes in hormonal levels and peripheral lipolysis respectively.     

Cell mediated and humoral immunity in chronic suppurative otitis media

The present study was carried out on 75 patients suffering from chronic otitis media and 25 healthy age and sex matched controls. The T. rosette percentage were depressed in malnouirished immunity (CMI), but once malnutrition was treated the CMI was improved. Anergy to challenge does of 2 : 4 DNCB was not observed in any groups. Weak response was observed in 4% of controls, 18.7% of chronic otitis media patients and 5.7% of post treatment cases. Serum IgG, IgA and IgM levels were elevated in chronic otitis media patients from controls but once the infections were eliminated by treatment their values became insignificant (p 0.05) from controls. Presence of Malnutrition significantly contributed to suppression of CMI response but no suppression of humoral immunity was observed.     

Supervised atenolol therapy in the management of hemodialysis hypertension

BACKGROUND: Uncontrolled hypertension continues to be a common problem, particularly in noncompliant hemodialysis patients. Atenolol, a water soluble beta-blocker has a prolonged half-life in renal failure and may serve as a useful antihypertensive agent in these patients. METHODS: Hypertension was diagnosed by ambulatory blood pressure monitoring for 44 hours during an interdialytic interval in eight chronic hemodialysis patients receiving no antihypertensive therapy. An average daytime blood pressure greater than 140/90 mm Hg or an average nighttime blood pressure greater than 120/80 mm Hg was used to define uncontrolled hypertension. Patients were then administered atenolol (25 mg) following hemodialysis three times a week. The efficacy of therapy was judged by ambulatory blood pressure monitoring three weeks after instituting atenolol therapy. Blood pressure loads above the threshold blood pressures during the day or night were also calculated and compared before and after three weeks of atenolol therapy. RESULTS: The mean 44-hour ambulatory blood pressure (ABP) fell from 144 +/- 14/80 +/- 7 mm Hg to 127 +/- 13/69 +/- 10 mm Hg (P < 0.001). The heart rate fell from 85 +/- 11 to 70 +/- 11 beats per minute. The systolic and diastolic blood pressure load was reduced from 71 +/- 25% and 30 +/- 24% to 35 +/- 26% and 11 +/- 17%, respectively (P < 0.001). There was a persistent antihypertensive effect over 44 hours. The blood pressure reduction was achieved without any increase in intradialytic symptomatic or asymptomatic hypotensive episodes, reduction in delivered dialysis, or statistically significant changes in serum potassium or glucose. CONCLUSIONS: A supervised administration of atenolol following hemodialysis effectively and safely controls hypertension in chronic hemodialysis patients. This therapy can be particularly valuable for noncompliant hemodialysis patients.