Delayed sternal closure (DSC) after cardiac surgery: outcome and prognostic markers

Abstract Background: Maintenance of an open sternotomy (OS) after a complicated cardiac operation is an adjunct in the treatment of the severely impaired heart. The purpose of this retrospective study was to evaluate the incidence, survival, and predictors of poor outcome for open chest management (OCM) with delayed sternal closure (DSC) at our department. Methods: Prolonged open chest (OC) was used in 179 of 5122 cardiac surgery patients between 2004 and 2008 (3.5%). We wanted to determine indications, mortality, postoperative complications, and predictors of outcome. Results: The incidence of OS was 3.5%, with 1.3% for isolated CABG, 2.4% for isolated valve, and 6.4% for combined procedures. Indications for OS were: hemodynamic compromise (110), intractable bleeding (19), arrhythmia (14), and cardiac edema or tamponade (36). 127 of the 179 patients with DSC (71%) survived. 52 patients died: 20 before DSC and 32 after this procedure. Mortality could be related to the indication for OS: With the indication “low cardiac output syndrome” (LCOS) the mortality was 34.5%, for bleeding it was 26.3%, for arrhythmias, 21.4%, and for tamponade on closure it was 16.7%. After DSC, deep sternal wound infection occurred in nine patients (5%), superficial infection in 4.7% of patients. There were 16 patients with postoperative stroke (8.9%) and 24 patients with need for dialysis (13.4%). Predictors of mortality by univariate analysis were VAD insertion, new onset of hemodialysis, reoperation for bleeding, mean length of duration of OS (survivors 3.4 days, nonsurvivors 6.5 days), and longer duration of high‐dose inotropic therapy. Conclusion: This study shows that OCM with DSC is a beneficial, therapeutic option in patients with postoperative LCOS, significant hemorrhage or intractable arrhythmias. However, patients with reoperation for bleeding, need for VAD, and particularly a prolonged delay before sternal closure continued to have a poor outcome. (J Card Surg 2011;26:22‐27)     

Resolution of Persistent Exudative Retinal Detachment in a Case of Sturge-Weber Syndrome with Anti-VEGF Administration

Purpose: Report the resolution of a persistent exudative retinal detachment in a patient with Sturge-Weber syndrome following intravitreal pegaptanib injection. Design: Case report. Methods: A 13-year-old male with Sturge-Weber syndrome presented with a choroidal hemangioma associated with an exudative retinal detachment that failed to resolve 6 months after external beam radiation therapy. Results: A single intravitreal pegaptanib injection resulted in 50% resolution of the detachment within 1 week and complete resolution within a month. Despite anatomic success, vision remained poor. Conclusions: VEGF likely plays a role in the pathogenesis of Sturge-Weber choroidal hemangioma-associated exudative retinal detachment and offers potential treatment.     

Ultrasound-guided breast-sparing surgery to improve cosmetic outcomes and quality of life. A prospective multicentre randomised controlled clinical trial comparing ultrasound-guided surgery to traditional palpation-guided surgery (COBALT trial)

Background

Breast-conserving surgery for breast cancer was developed as a method to preserve healthy breast tissue, thereby improving cosmetic outcomes. Thus far, the primary aim of breast-conserving surgery has been the achievement of tumour-free resection margins and prevention of local recurrence, whereas the cosmetic outcome has been considered less important. Large studies have reported poor cosmetic outcomes in 20-40% of patients after breast-conserving surgery, with the volume of the resected breast tissue being the major determinant. There is clear evidence for the efficacy of ultrasonography in the resection of nonpalpable tumours. Surgical resection of palpable breast cancer is performed with guidance by intra-operative palpation. These palpation-guided excisions often result in an unnecessarily wide resection of adjacent healthy breast tissue, while the rate of tumour-involved resection margins is still high. It is hypothesised that the use of intra-operative ultrasonography in the excision of palpable breast cancer will improve the ability to spare healthy breast tissue while maintaining or even improving the oncological margin status. The aim of this study is to compare ultrasound-guided surgery for palpable tumours with the standard palpation-guided surgery in terms of the extent of healthy breast tissue resection, the percentage of tumour-free margins, cosmetic outcomes and quality of life.

Methods/design

In this prospective multicentre randomised controlled clinical trial, 120 women who have been diagnosed with palpable early-stage (T1-2N0-1) primary invasive breast cancer and deemed suitable for breast-conserving surgery will be randomised between ultrasound-guided surgery and palpation-guided surgery. With this sample size, an expected 20% reduction of resected breast tissue and an 18% difference in tumour-free margins can be detected with a power of 80%. Secondary endpoints include cosmetic outcomes and quality of life. The rationale, study design and planned analyses are described.

Conclusion

The COBALT trial is a prospective, multicentre, randomised controlled study to assess the efficacy of ultrasound-guided breast-conserving surgery in patients with palpable early-stage primary invasive breast cancer in terms of the sparing of breast tissue, oncological margin status, cosmetic outcomes and quality of life.

Trial Registration Number

Netherlands Trial Register (NTR): NTR2579     

The incidence, risk factors, and outcome of transfusion-related acute lung injury in a cohort of cardiac surgery patients: a prospective nested case-control study

Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related morbidity and mortality. Both antibodies and bioactive lipids that have accumulated during storage of blood have been implicated in TRALI pathogenesis. In a single-center, nested, case-control study, patients were prospectively observed for onset of TRALI according to the consensus definition. Of 668 patients, 16 patients (2.4%) developed TRALI. Patient-related risk factors for onset of TRALI were age and time on the cardiopulmonary bypass. Transfusion-related risk factors were total amount of blood products (odds ratio [OR] = 1.2; 95% confidence interval [CI], 1.03-1.44), number of red blood cells stored more than 14 days (OR = 1.6; 95% CI, 1.04-2.37), total amount of plasma (OR = 1.2; 95% CI, 1.03-1.44), presence of antibodies in donor plasma (OR = 8.8; 95% CI, 1.8-44), and total amount of transfused bioactive lipids (OR = 1.0; 95% CI, 1.00-1.07). When adjusted for patient risk factors, only the presence of antibodies in the associated blood products remained a risk factor for TRALI (OR = 14.2; 95% CI, 1.5-132). In-hospital mortality of TRALI was 13% compared with 0% and 3% in transfused and nontransfused patients, respectively (P < .05). In conclusion, the incidence of TRALI is high in cardiac surgery patients and associated with adverse outcome. Our results suggest that cardiac surgery patients may benefit from exclusion of blood products containing HLA/HNA antibodies.     

Aging effects on exercise-induced alternations in plasma acylated ghrelin and leptin in male rats

Ghrelin and exercise have been known to stimulate the release of growth hormone which is related to the glucose metabolism. However, the age effects of exercise on ghrelin in energy consumption remain unclear. Young (3 month old) and middle-aged (12 month old) Sprague–Dawley male rats were overnight fasted, and then randomly partitioned into exercise and control groups. Exercise groups swam for 20 min in 25°C water. Rats immersed in 25°C water for 20 min were used as control animals. All blood samples were collected before and 10, 20, 30, and 60 min after initiation of exercise via the right jugular vein. Our results indicated that the swimming regimen decreased the secretion of acylated ghrelin and insulin, but increased the secretion of leptin, lactate, and glucose. In addition, exercise significantly amplified the inverse correlation between leptin and acylated ghrelin (r < −0.6) in middle-age group. Both the above findings were not emphasized in related articles before. Moreover, the time courses of these changes were slightly different in young and middle-aged rats. In basal metabolic characteristics, body weight and the plasma lactate, glucose, insulin, and leptin are higher in middle-age group than that in young group. In conclusion, compared with young rats, middle-aged rats have higher basal body weight, plasma glucose, insulin, and leptin, but age had no effect on the level of plasma acylated ghrelin. A 20-min exercise regimen decreased acylated ghrelin and increased leptin with inverse correlation between them which was strengthened during exercise, but were not influenced by age.     

Palliative inpatients in general hospitals: a one day observational study in Belgium

Background  

Hospital care plays a major role at the end-of-life. But little is known about the overall size and characteristics of the palliative inpatient population. The aim of our study was to analyse these aspects.     

Antimicrobial activities of the methanol extract,fractions and compounds from <Emphasis Type="Italic">Ficus polita</Emphasis> Vahl. (Moraceae)

Background  

Many plants of the family Moraceae are used in the treatment of infectious diseases. Ficus polita Vahl., an edible plant belonging to this family is used traditionally in case of dyspepsia, infectious diseases, abdominal pains and diarrhea. The present work was designed to assess the antimicrobial activity of the methanol extract from the roots of F. polita (FPR), as well as that of its fractions (FPR1-5) and two of the eight isolated compounds, namely euphol-3- O -cinnamate (1) and (E)- 3,5,4'-trihydroxy-stilbene-3,5- O-β-D -diglucopyranoside (8).     

Introducing graph theory to track for neuroplastic alterations in the resting human brain: a transcranial direct current stimulation study

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that alters cortical excitability and activity in a polarity-dependent way. Stimulation for a few minutes has been shown to induce plastic alterations of cortical excitability and to improve cognitive performance. These effects might be related to stimulation-induced alterations of functional cortical network connectivity. We aimed to investigate the impact of tDCS on cortical network function by functional connectivity and graph theoretical analysis of the BOLD fMRI spontaneous activity. fMRI resting-state datasets were acquired immediately before and after 10-min bipolar tDCS during rest, with the anode placed over the left primary motor cortex (M1) and the cathode over the contralateral frontopolar cortex. For each dataset, grey matter voxel-based synchronization matrices were calculated and thresholded to construct undirected graphs. Nodal connectivity degree and minimum path length maps were calculated and compared before and after tDCS. Nodal minimum path lengths significantly increased in the left somatomotor (SM1) cortex after anodal tDCS, which means that the number of direct functional connections from the left SM1 to topologically distant grey matter voxels significantly decreased. In contrast, functional coupling between premotor and superior parietal areas with the left SM1 significantly increased. Additionally, the nodal connectivity degree in the left posterior cingulate cortex (PCC) area as well as in the right dorsolateral prefrontal cortex (right DLPFC) significantly increased. In summary, we provide initial support that tDCS-induced neuroplastic alterations might be related to functional connectivity changes in the human brain. Additionally, we propose our approach as a powerful method to track for neuroplastic changes in the human brain.