Atrial fibrillation after pulmonary lobectomy for lung cancer affects long-term survival in a prospective single-center study

<p>Abstract</p> <p>Background</p> <p>Atrial fibrillation (AF) after thoracic surgery is a continuing source of morbidity and mortality. The effect of postoperative AF on long-term survival however has not been studied. Our aim was to evaluate the impact of AF on early outcome and on survival > 5 years after pulmonary lobectomy for lung cancer.</p> <p>Methods</p> <p>From 1996 to June 2009, 454 consecutive patients undergoing lobectomy for lung cancer were enrolled and followed-up until death or study end (October 2010). Patients with postoperative AF were identified; AF was investigated with reference to its predictors and to short- and long-term survival (> 5 years).</p> <p>Results</p> <p>Hospital mortality accounted for 7 patients (1.5%), while postoperative AF occurred in 45 (9.9%). Independent AF predictors were: preoperative paroxysmal AF (odds ratio [OR] 5.91; 95%CI 2.07 to 16.88), postoperative blood transfusion (OR 3.61; 95%CI 1.67 to 7.82) and postoperative fibro-bronchoscopy (OR 3.39; 95%CI 1.48 to 7.79). Patients with AF experienced higher hospital mortality (6.7% vs. 1.0%, p = 0.024), longer hospitalization (15.3 ± 10.1 vs. 12.2 ± 5.2 days, p = 0.001) and higher intensive care unit admission rate (13.3% vs. 3.9%, p = 0.015). The median follow-up was 36 months (maximum: 179 months). Among the 445 discharged subjects with complete follow-up, postoperative AF was not an independent predictor of mortality; however, among the 151 5-year survivors, postoperative AF independently predicted poorer long-term survival (HR 3.75; 95%CI 1.44 to 9.08).</p> <p>Conclusion</p> <p>AF after pulmonary lobectomy for lung cancer, in addition to causing higher hospital morbidity and mortality, predicts poorer long-term outcome in 5-year survivors.</p

THE BASE SYSTEM: A SCHOOL-WIDE POSITIVE BEHAVIOUR SUPPORT TOOL TO FACILITATE EVIDENCE-BASED DIGITAL INTERVENTION PRACTICES

The Positive Behaviour Intervention and Support system is a framework aimed to introduce a change at school-wide level. It promotes a disciplinary system change process, from a reactive punishment- based strategies of specific student misbehaviours to a proactive system, where different behavioural principles such as the modelling and reinforcement of positive prosocial students’ behaviours are applied to improve school values and to create a positive climate. This paper presents the Behavioural Assessment to improve School Environment (BASE) system and the BASE repository. The BASE system supports evidence-based digital intervention practices for stimulating the academic, social, emotional, and behavioural competencies of all students. The BASE repository is a collection of good practices, tools, and instructional contents. Both of the tools are able to support and facilitate, through the use of mobile devices and a web-based responsive system, different prevention and instructional practices at the three-tiers PBS model. At the first level of prevention (Tier 1) the system allows to the school PBS team to define the Expectation Matrix, a set of positive behaviours grouped according to predefined school values and locations. Moreover, the PBS team members are able to define the list of problem behaviours, classifying them in minor and major. The matrix and the list of minor and major problem behaviours are at the base of the development of a screening tool for identifying behavioural risk problems, the Positive Office Referral and the Office Disciplinary Referral tools. At the target prevention level (Tier 2) the BASE application provides the Check-in/Check-out (CICO) tool, as PBIS recommends. It is addressed to a targeted group of students, resulted unresponsive to the Tier I, and implements the practice of ‘Positive reinforcement contingent on meeting behavioural goals’ throughout a reward system. At the intensive prevention level (Tier 3) the system allows users to perform Functional Behaviour Assessment for students considered unresponsive to Tier I and II and to create customized measurement tools for designing single case studies. The measure can be assigned to the observers able to collect data and organize them in phases. A TAU analysis algorithm is applied to the gathered data for showing the effectiveness of intervention. In the BASE application, each student can access to the system with personal credentials and to visualize his significant progresses into a smart dashboard. The BASE repository represents a hub for digital resources collection concerning both theoretical and methodological aspects of the PBIS approach. The Internet users interested to know the European experience of the involved partner schools, and to enlarge their knowledge about the principles to implement the PBIS in their own school, can find a first set of multimedia contents, webinars, collection of good practices gathered during the lifespan of the European Erasmus+ BASE project. The repository facilitates the finding of high-quality contents and represents a learning corner and an important knowledge repository for teachers and health professionals to understand and apply this approach

Durability of bioprosthetic aortic valves in patients under the age of 60 years - Rationale and design of the international INDURE registry

Background: There is an ever-growing number of patients requiring aortic valve replacement (AVR). Limited data is available on the long-term outcomes and structural integrity of bioprosthetic valves in younger patients undergoing surgical AVR. Methods: The INSPIRIS RESILIA Durability Registry (INDURE) is a prospective, open-label, multicentre, international registry with a follow-up of 5 years to assess clinical outcomes of patients younger than 60 years who undergo surgical AVR using the INSPIRIS RESILIA aortic valve. INDURE will be conducted across 20-22 sites in Europe and Canada and intends to enrol minimum of 400 patients. Patients will be included if they are scheduled to undergo AVR with or without concomitant root replacement and/or coronary bypass surgery. The primary objectives are to 1) determine VARC-2 defined time-related valve safety at one-year (depicted as freedom from events) and 2) determine freedom from stage 3 structural valve degeneration (SVD) presenting as morphological abnormalities and severe haemodynamic valve degeneration at 5 years. Secondary objectives include the assessment of the haemodynamic performance of the valve, all stages of SVD, potential valve-in-valve procedures, clinical outcomes (in terms of New York Heart Association [NYHA] function class and freedom from valve-related rehospitalisation) and change in patient quality-of-life. Discussion: INDURE is a prospective, multicentre registry in Europe and Canada, which will provide much needed data on the long-term performance of bioprosthetic valves in general and the INSPIRIS RESILIA valve in particular. The data may help to gather a deeper understanding of the longevity of bioprosthetic valves and may expand the use of bioprosthetic valves in patients under the age of 60 years. Trial registration: ClinicalTrials.gov identifier: NCT03666741 (registration received September, 12th, 2018)

Comparative Analysis of Prothrombin Complex Concentrate and Fresh Frozen Plasma in the Management of Perioperative Bleeding after Coronary Artery Bypass Grafting

Background and Aim: Recent studies suggested that prothrombin complex concentrate (PCC) might be more effective than fresh frozen plasma (FFP) to reduce red blood cell (RBC) transfusion requirement after cardiac surgery. The benefits and risks associated with the use of PCC over FFP have been investigated in this study including patients undergoing isolated coronary artery bypass grafting(CABG) from a prospective, multicenter registry. Methods: This is a comparative analysis of 416 patients who received postoperatively FFP and 119 patients who received PCC with or without FFP after isolated CABG. Results: Mixed-effects regression analyses adjusted for multiple covariates and participating centers showed that PCC significantly decreased RBC transfusion (67.2% vs. 87.5%, adjusted OR 0.319, 95%CI 0.136-0.752) and platelet transfusion requirements (11.8% vs. 45.2%, adjusted OR 0.238, 95%CI 0.097-0.566) compared with FFP. The PCC cohort received a mean of 2.7\ub13.7 (median, 2.0, IQR 4) units of RBC and the FFP cohort received a mean of 4.9\ub16.3 (median, 3.0, IQR 4) units of RBC (adjusted coefficient, -1.926, 95%CI -3.357-0.494). The use of PCC increased the risk of KDIGO acute kidney injury (41.4% vs. 28.2%, adjusted OR 2.300, 1.203-4.400), but not of KDIGO acute kidney injury stage 3 (6.0% vs. 8.0%, OR 0.850, 95%CI 0.258-2.796) when compared with the FFP cohort. Conclusions: These results suggest that the use of PCC compared with FFP may reduce the need of blood transfusion after CABG. In view of the observational nature of this study, these results shoul

Durability of bioprosthetic aortic valves in patients under the age of 60 years - Rationale and design of the international INDURE registry

Background: There is an ever-growing number of patients requiring aortic valve replacement (AVR). Limited data is available on the long-term outcomes and structural integrity of bioprosthetic valves in younger patients undergoing surgical AVR. Methods: The INSPIRIS RESILIA Durability Registry (INDURE) is a prospective, open-label, multicentre, international registry with a follow-up of 5 years to assess clinical outcomes of patients younger than 60 years who undergo surgical AVR using the INS

Determinants of outcomes following surgery for type A acute aortic dissection: the UK National Adult Cardiac Surgical Audit

Aims  Operability of type A acute aortic dissections (TAAAD) is currently based on non-standardized decision-making process, and it lacks a disease-specific risk evaluation model that can predict mortality. We investigated patient, intraoperative data, surgeon, and centre-related variables for patients who underwent TAAAD in the UK. Methods and results We identified 4203 patients undergoing TAAAD surgery in the UK (2009–18), who were enrolled into the UK National Adult Cardiac Surgical Audit dataset. The primary outcome was operative mortality. A multivariable logistic regression analysis was performed with fast backward elimination of variables and the bootstrap-based optimism-correction was adopted to assess model performance. Variation related to hospital or surgeon effects were quantified by a generalized mixed linear model and risk-adjusted funnel plots by displaying the individual standardized mortality ratio against expected deaths. Final variables retained in the model were: age [odds ratio (OR) 1.02, 95% confidence interval (CI) 1.02–1.03; P < 0.001]; malperfusion (OR 1.79, 95% CI 1.51–2.12; P < 0.001); left ventricular ejection fraction (moderate: OR 1.40, 95% CI 1.14–1.71; P = 0.001; poor: OR 2.83, 95% CI 1.90–4.21; P < 0.001); previous cardiac surgery (OR 2.29, 95% CI 1.71–3.07; P < 0.001); preoperative mechanical ventilation (OR 2.76, 95% CI 2.00–3.80; P < 0.001); preoperative resuscitation (OR 3.36, 95% CI 1.14–9.87; P = 0.028); and concomitant coronary artery bypass grafting (OR 2.29, 95% CI 1.86–2.83; P < 0.001). We found a significant inverse relationship between surgeons but not centre annual volume with outcomes. Conclusions  Patient characteristics, intraoperative factors, cardiac centre, and high-volume surgeons are strong determinants of outcomes following TAAAD surgery. These findings may help refining clinical decision-making, supporting patient counselling and be used by policy makers for quality assurance and service provision improvement

Fish, Fish-Derived n-3 Fatty Acids, and Risk of Incident Atrial Fibrillation in the Atherosclerosis Risk in Communities (ARIC) Study

Results of observational and experimental studies investigating the association between intake of long-chain n-3 polyunsaturated fatty acids (PUFAs) and risk of atrial fibrillation (AF) have been inconsistent.We studied the association of fish and the fish-derived n-3 PUFAs eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) with the risk of incident AF in individuals aged 45-64 from the Atherosclerosis Risk in Communities (ARIC) cohort (n = 14,222, 27% African Americans). Intake of fish and of DHA and EPA were measured via food frequency questionnaire. Plasma levels of DHA and EPA were measured in phospholipids in a subset of participants (n = 3,757). Incident AF was identified through the end of 2008 using ECGs, hospital discharge codes and death certificates. Cox proportional hazards regression was used to estimate hazard ratios of AF by quartiles of n-3 PUFAs or by fish intake.During the average follow-up of 17.6 years, 1,604 AF events were identified. In multivariable analyses, total fish intake and dietary DHA and EPA were not associated with AF risk. Higher intake of oily fish and canned tuna was associated with a nonsignificant lower risk of AF (p for trend = 0.09). Phospholipid levels of DHA+EPA were not related to incident AF. However, DHA and EPA showed differential associations with AF risk when analyzed separately, with lower risk of AF in those with higher levels of DHA but no association between EPA levels and AF risk.In this racially diverse sample, dietary intake of fish and fish-derived n-3 fatty acids, as well as plasma biomarkers of fish intake, were not associated with AF risk

Dose dependent effect of statins on postoperative atrial fibrillation after cardiac surgery among patients treated with beta blockers

<p>Abstract</p> <p>Background</p> <p>Previous studies on the effects of Statins in preventing atrial fibrillation (AF) after cardiac surgery have shown conflicting results. Whether statins prevent AF in patients treated with postoperative beta blockers and whether the statin-effect is dose related are unknown.</p> <p>Methods</p> <p>We retrospectively studied 1936 consecutive patients who underwent coronary artery bypass graft (CABG) (n = 1493) or valve surgery (n = 443) at the Minneapolis Veterans Affairs Medical Center. All patients were in sinus rhythm before the surgery. Postoperative beta blockers were administered routinely (92% within 24 hours postoperatively).</p> <p>Results</p> <p>Mean age was 66+10 years and 68% of the patients were taking Statins. Postoperative AF occurred in 588 (30%) patients and led to longer length of stay in the intensive care unit versus those without AF (5.1+7.6 days versus 2.5+2.3 days, p < 0.0001). Patients with a past history of AF had a 5 times higher risk of postoperative AF (odds ratio 5.1; 95% confidence interval 3.4 to 7.7; p < 0.0001). AF occurred in 31% of patients taking statins versus 29% of the others (p = 0.49). In multivariable analysis, statins were not associated with AF (odds ratio (OR) 0.93, 95% confidence interval (CI) 0.7 to 1.2; p = 0.59). However, in a subgroup analysis, the patients treated with Simvastatin >20 mg daily had a 36% reduction in the risk of postoperative AF (OR 0.64, 95% CI 0.43 to 0.6; p = 0.03) in comparison to those taking lower dosages.</p> <p>Conclusion</p> <p>Among cardiac surgery patients treated with postoperative beta blockers Statin treatment reduces the incidence of postoperative AF when used at higher dosages</p

Heat shock proteins in stabilization of spontaneously restored sinus rhythm in permanent atrial fibrillation patients after mitral valve surgery

A spontaneously restored sinus rhythm in permanent atrial fibrillation patients has been often observed after mitral valve (MV) surgery, but persisting duration in sinus rhythm varies from patient to patient. Heat shock proteins (Hsps) may be involved in pathogenesis of atrial fibrillation. We hypothesized that stabilization of restored sinus rhythm is associated with expression of Hsps in the atria. To test this hypothesis, clinical data, biopsies of right atrial appendage, and blood samples were collected from 135 atrial fibrillation patients who spontaneously restored sinus rhythm after conventional isolated MV replacement. Comparison was made between patients who had recurrence of atrial fibrillation within 7 days (AF) vs. patients with persisted sinus rhythm for more than 7 days (SR). Results showed that SR patients had higher activity of heat shock transcription factor 1 (HSF1) as well as upregulated expressions of heat shock cognate 70, Hsp70, and Hsp27 in the tissues. The activation of HSF1–Hsps pathway was associated with less-aggressive pathogenesis as reflected by lower rates of myolysis, apoptosis, interstitial fibrosis, and inflammation in SR patients. However, Hsp60 was lower in both tissue and plasma in SR patients, and was positively correlated with apoptosis, interstitial fibrosis, and inflammation. These findings suggest that the Hsps play important roles in stabilization of restored sinus rhythm after MV surgery by inhibiting AF-related atrial remodeling and arrhythmogenic substrates in atrial fibrillation patients. Low circulating Hsp60 levels preoperatively might predict a stable spontaneously restored sinus rhythm postoperatively

Numerical simulation of the filling and curing stages in reaction injection moulding, using CFX

Mestrado em Engenharia MecânicaOs métodos habitualmente utilizados para a simulação de injecção em moldes envolvem um número considerável de simplificações, originando reduções significativas do esforço computacional mas, nalguns casos também limitações. Neste trabalho são efectuadas simulações de Reaction Injection Moulding (RIM) com o mínimo de simplificações, através da utilização do software de CFD multi-objectivos CFX, concebido para a simulação numérica de escoamentos e transferência de calor e massa. Verifica-se que o modelo homogéneo para escoamentos multifásicos do CFX, geralmente considerado o apropriado para a modelação de escoamentos de superfície livre em que as fases estão completamente estratificadas, é incapaz de modelar correctamente o processo de enchimento. Este problema é ultrapassado através da implementação do modelo não homogéneo juntamente com a condição de fronteira de escorregamento livre para o ar. A reacção de cura é implementada no código como uma equação de transporte para uma variável escalar adicional, com um termo fonte. São testados vários esquemas transitórios e advectivos, com vista ao reconhecimentos de quais os que produzem os resultados mais precisos. Finalmente, as equações de conservação de massa, quantidade de movimento, cura e energia são implementadas conjuntamente para simular os processos simultâneos de enchimento e cura presentes no processo RIM. Os resultados numéricos obtidos reproduzem com boa fidelidade outros resultados numéricos e experimentais disponíveis, sendo necessários no entanto tempos de computação consideravelmente longos para efectuar as simulações. ABSTRACT: Commonly used methods for injection moulding simulation involve considerable number of simplifications, leading to a significant reduction of the computational effort but, in some cases also to limitations. In this work, Reaction Injection Moulding (RIM) simulations are performed with minimum of simplifications, by using the general purpose CFD software package CFX, designed for numerical simulation of fluid flow and heat and mass transfer. The CFX’s homogeneous multiphase flow model, which is generally considered to be the appropriate choice for modelling free surface flows where the phases are completely stratified and the interface is well defined, is shown to be unable to model the filling process correctly. This problem is overcome through the implementation of the inhomogeneous model in combination with the free-slip boundary condition for the air phase. The cure reaction is implemented in the code as a transport equation for an additional scalar variable, with a source term. Various transient and advection schemes are tested to determine which ones produce the most accurate results. Finally, the mass conservation, momentum, cure and energy equations are implemented all together to simulate the simultaneous filling and curing processes present in the RIM process. The obtained numerical results show a good global accuracy when compared with other available numerical and experimental results, though considerably long computation times are required to perform the simulations