Coexisting Cardiac and Hematologic Disorders.

Patients with concomitant cardiac and hematologic disorders presenting for noncardiac surgery are challenging. Anemic patients with cardiac disease should be approached in a methodical fashion. Transfusion triggers and target should be based on underlying symptomatology. The approach to anticoagulation management in patients with artificial heart valves, cardiac devices, or severe heart failure in the operative setting must encompass a complete understanding of the rationale of a patient\u27s therapy as well as calculate the risk of changing this regimen. This article focuses common disorders and discusses strategies to optimize care in patients with coexisting cardiac and hematologic disease

Hierarchy of stratigraphic forcing: Example from Middle Pennsylvanian shelf carbonates of the Paradox basin

Middle Pennsylvanian (Desmoinesian) shelf carbonates in the southwestern Paradox basin display three superimposed orders of stratigraphic cyclicity with a systematic vertical succession of facies, cycle, and sequence stacking patterns. Fifth-order cycles [34 cycles in a 645-ft (197-m) section; average 20 ft (6.1 m) thick; mean period 29,000 years] are grouped into fourth-order sequences [average 100 ft (30 m) thick; mean period 257,000 years], which in turn stack vertically to define a third-order sequence [650+ ft (200+ m) thick; 2-3 m.y. duration]. Fifth-order cycles are composed of shallow ing-upward packages of predominantly subtidal shelf carbonates with sharp cycle boundaries (either exposure or flooding surfaces). Fifth-order cycles are packaged into fourth-order sequences bounded by regionally correlative subaerial exposure surfaces. These type 1 sequences contain a downdip, restricted lowstand wedge of evaporites and quartz clastics in topographic lows on the Paradox shelf (intrashelf depressions). The lowstand systems tract is overlain by a regionally correlative transgressive shaly mudstone (condensed section) and a highstand systems tract composed of thinning-upward, aggradational fifth-order cycles. Systematic variation in the thickness of fourth-order sequences (thinning upward followed by thickening upward) and systematic variations in the number of fifth-order cycles and fourth-order sequences (decreasing followed by increasing number) defines a third-order accommodation trend that is also regionally correlative. High-frequency cycles and sequences are interpreted as predominantly aggradational allocycles generated in response to composite fourth- and fifth-order glacio-eustatic sea-level fluctuations. Two different orbital forcing (Milankovitch) scenarios are evaluated to explain the composite stratigraphic cyclicity of the Paradox sequences, each of which is plausible given Desmoinesian age estimates. The cycle, sequence, and facies stacking patterns have been replicated by means of computer modeling by superimposing composite high-frequency glacio-eustasy atop regional subsidence using depth-dependent, sedimentation

Hierarchy of stratigraphic forcing: Example from Middle Pennsylvanian shelf carbonates of the Paradox basin

Middle Pennsylvanian (Desmoinesian) shelf carbonates in the southwestern Paradox basin display three superimposed orders of stratigraphic cyclicity with a systematic vertical succession of facies, cycle, and sequence stacking patterns. Fifth-order cycles [34 cycles in a 645-ft (197-m) section; average 20 ft (6.1 m) thick; mean period 29,000 years] are grouped into fourth-order sequences [average 100 ft (30 m) thick; mean period 257,000 years], which in turn stack vertically to define a third-order sequence [650+ ft (200+ m) thick; 2-3 m.y. duration]. Fifth-order cycles are composed of shallow ing-upward packages of predominantly subtidal shelf carbonates with sharp cycle boundaries (either exposure or flooding surfaces). Fifth-order cycles are packaged into fourth-order sequences bounded by regionally correlative subaerial exposure surfaces. These type 1 sequences contain a downdip, restricted lowstand wedge of evaporites and quartz clastics in topographic lows on the Paradox shelf (intrashelf depressions). The lowstand systems tract is overlain by a regionally correlative transgressive shaly mudstone (condensed section) and a highstand systems tract composed of thinning-upward, aggradational fifth-order cycles. Systematic variation in the thickness of fourth-order sequences (thinning upward followed by thickening upward) and systematic variations in the number of fifth-order cycles and fourth-order sequences (decreasing followed by increasing number) defines a third-order accommodation trend that is also regionally correlative. High-frequency cycles and sequences are interpreted as predominantly aggradational allocycles generated in response to composite fourth- and fifth-order glacio-eustatic sea-level fluctuations. Two different orbital forcing (Milankovitch) scenarios are evaluated to explain the composite stratigraphic cyclicity of the Paradox sequences, each of which is plausible given Desmoinesian age estimates. The cycle, sequence, and facies stacking patterns have been replicated by means of computer modeling by superimposing composite high-frequency glacio-eustasy atop regional subsidence using depth-dependent, sedimentation

Preventing Isolated Perioperative Reintubation: Who is at highest risk?

Objectives: 1. We aim to characterize IPR nationally through a retrospective review of the National Surgical Quality Improvement Program participant user file (NSQIP PUF). 2.Identify risk factors for IPR including analysis of procedure type and preoperative characteristics.https://jdc.jefferson.edu/patientsafetyposters/1041/thumbnail.jp

How I perform totally endoscopic robotic mitral valve repair.

A sixty-two-year-old male presented with significant symptoms related to severe mitral regurgitation with posterior leaflet flail and prolapse on transesophageal echocardiogram (TEE). Preoperative computed tomography (CT) angiography showed normal caliber thoracoabdominal aorta and patent access vessels. The patient underwent totally endoscopic robotic mitral valve repair (rMVr) with left atrial CryoMAZE procedure

Breastfeeding and the origins of health: Interdisciplinary perspectives and priorities

Breastfeeding and human milk (HM) are critically important to maternal, infant and population health. This paper summarizes the proceedings of a workshop that convened a multidisciplinary panel of researchers to identify key priorities and anticipated breakthroughs in breastfeeding and HM research, discuss perceived barriers and challenges to achieving these breakthroughs and propose a constructive action plan to maximize the impact of future research in this field. Priority research areas identified were as follows: (1) addressing low breastfeeding rates and inequities using mixed methods, community partnerships and implementation science approaches; (2) improving awareness of evidence-based benefits, challenges and complexities of breastfeeding and HM among health practitioners and the public; (3) identifying differential impacts of alternative modes of HM feeding including expressed/pumped milk, donor milk and shared milk; and (4) developing a mechanistic understanding of the health effects of breastfeeding and the contributors to HM composition and variability. Key barriers and challenges included (1) overcoming methodological limitations of epidemiological breastfeeding research and mechanistic HM research; (2) counteracting ‘breastfeeding denialism’ arising from negative personal breastfeeding experiences; (3) distinguishing and aligning research and advocacy efforts; and (4) managing real and perceived conflicts of interest. To advance research on breastfeeding and HM and maximize the reach and impact of this research, larger investments are needed, interdisciplinary collaboration is essential, and the scientific community must engage families and other stakeholders in research planning and knowledge translation

Earliest Triassic microbialites in the South China Block and other areas; controls on their growth and distribution

Earliest Triassic microbialites (ETMs) and inorganic carbonate crystal fans formed after the end-Permian mass extinction (ca. 251.4 Ma) within the basal Triassic Hindeodus parvus conodont zone. ETMs are distinguished from rarer, and more regional, subsequent Triassic microbialites. Large differences in ETMs between northern and southern areas of the South China block suggest geographic provinces, and ETMs are most abundant throughout the equatorial Tethys Ocean with further geographic variation. ETMs occur in shallow-marine shelves in a superanoxic stratified ocean and form the only widespread Phanerozoic microbialites with structures similar to those of the Cambro-Ordovician, and briefly after the latest Ordovician, Late Silurian and Late Devonian extinctions. ETMs disappeared long before the mid-Triassic biotic recovery, but it is not clear why, if they are interpreted as disaster taxa. In general, ETM occurrence suggests that microbially mediated calcification occurred where upwelled carbonate-rich anoxic waters mixed with warm aerated surface waters, forming regional dysoxia, so that extreme carbonate supersaturation and dysoxic conditions were both required for their growth. Long-term oceanic and atmospheric changes may have contributed to a trigger for ETM formation. In equatorial western Pangea, the earliest microbialites are late Early Triassic, but it is possible that ETMs could exist in western Pangea, if well-preserved earliest Triassic facies are discovered in future work

Effect of lipid-lowering medications in patients with coronary artery bypass grafting surgery outcomes

Background: Increased life expectancy and improved medical technology allow increasing numbers of elderly patients to undergo cardiac surgery. Elderly patients may be at greater risk of postoperative morbidity and mortality. Complications can lead to worsened quality of life, shortened life expectancy and higher healthcare costs. Reducing perioperative complications, especially severe adverse events, is key to improving outcomes in patients undergoing cardiac surgery. The objective of this study is to determine whether perioperative lipid-lowering medication use is associated with a reduced risk of complications and mortality after coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). Methods: After IRB approval, we reviewed charts of 9,518 patients who underwent cardiac surgery with CPB at three medical centers between July 2001 and June 2015. The relationship between perioperative lipid-lowering treatment and postoperative outcome was investigated. 3,988 patients who underwent CABG met inclusion criteria and were analyzed. Patients were divided into lipid-lowering or non-lipid-lowering treatment groups. Results: A total of 3,988 patients were included in the final analysis. Compared to the patients without lipid-lowering medications, the patients with lipid-lowering medications had lower postoperative neurologic complications and overall mortality (P \u3c 0.05). Propensity weighted risk-adjustment showed that lipid-lowering medication reduced in-hospital total complications (odds ratio (OR) = 0.856; 95% CI 0.781-0.938; P \u3c 0.001); all neurologic complications (OR = 0.572; 95% CI 0.441-0.739; P \u3c 0.001) including stroke (OR = 0.481; 95% CI 0.349-0.654; P \u3c 0.001); in-hospital mortality (OR = 0.616; 95% CI 0.432-0.869; P = 0.006; P \u3c 0.001); and overall mortality (OR = 0.723; 95% CI 0.634-0.824; P \u3c 0.001). In addition, the results indicated postoperative lipid-lowering medication use was associated with improved long-term survival in this patient population. Conclusions: Perioperative lipid-lowering medication use was associated with significantly reduced postoperative adverse events and improved overall outcome in elderly patients undergoing CABG surgery with CPB

Robotically Assisted Mitral Valve Repair—Port-Only Totally Endoscopic Approach

Robotic mitral valve repair (MVR) is an emerging option to treat degenerative valve disease. Compared to open thoracotomy, robotic mitral valve surgery has been shown to afford decreased postoperative length of stay with comparable rates of mortality and morbidity. Among the variety of techniques for robotic MVR, the totally endoscopic approach remains the least invasive method to date. In this report, we describe our technique for totally endoscopic robotically-assisted MVR. In particular, we seek to highlight the use of several unique techniques in MVR. Percutaneous cannulation with use of the endoballoon is employed for cardiopulmonary bypass (CPB), thus avoiding traditional aortic cross-clamping. Moreover, intercostal nerve cryoanesthesia is performed from T3–T9 to reduce post-operative pain and aid in reducing opioid management. Barbed, nonabsorbable sutures are used throughout the procedure (for left atrial appendage closure, mitral valve annuloplasty band placement, left atrial closure, pericardial re-approximation), eliminating the need for knot-tying at several steps. We also detail the installation of two sets of neochords for mitral regurgitation and the fastening of the mitral annuloplasty band. Finally, we would like to highlight the small size of each port used in the case (eight millimeters maximum diameter). Taken together, these features of the robotic platform make it notable for its minimally invasive approach to MVR

A hierarchical latent response model for inferences about examinee engagement in terms of guessing and item‐level non‐response

In low‐stakes assessments, test performance has few or no consequences for examinees themselves, so that examinees may not be fully engaged when answering the items. Instead of engaging in solution behaviour, disengaged examinees might randomly guess or generate no response at all. When ignored, examinee disengagement poses a severe threat to the validity of results obtained from low‐stakes assessments. Statistical modelling approaches in educational measurement have been proposed that account for non‐response or for guessing, but do not consider both types of disengaged behaviour simultaneously. We bring together research on modelling examinee engagement and research on missing values and present a hierarchical latent response model for identifying and modelling the processes associated with examinee disengagement jointly with the processes associated with engaged responses. To that end, we employ a mixture model that identifies disengagement at the item‐by‐examinee level by assuming different data‐generating processes underlying item responses and omissions, respectively, as well as response times associated with engaged and disengaged behaviour. By modelling examinee engagement with a latent response framework, the model allows assessing how examinee engagement relates to ability and speed as well as to identify items that are likely to evoke disengaged test‐taking behaviour. An illustration of the model by means of an application to real data is presented