Effect of Diabetes on Nitric Oxide Metabolism During Cardiac Surgery

The metabolism of nitric oxide (NO) during cardiac surgery is unclear. We studied the effect of diabetes on NO metabolism during cardiac surgery in 40 subjects (20 with diabetes and 20 without diabetes). The patients were randomized to receive an infusion of physiological saline or nitroglycerin (GTN) at 1 g kg–1 min–1 starting 10 min before the initiation of cardiopulmonary bypass and then continuing for a period of 4 h. Blood and urine samples were collected at several time points for up to 8 h. NO metabolites were determined by the measurement of nitrate/nitrite (NOx, mol/mmol creatinine) and cyclic guanosine monophosphate (cGMP, nmol/mmol creatinine) in plasma and urine. Plasma insulin levels were also determined at selected time points. Plasma NOx levels before surgery were significantly elevated in the group with diabetes compared with the group without diabetes (P < 0.001), and values were further increased during surgery in the former (P 0.005) but not in the latter (P 0.8). The greater plasma NOx values in patients with diabetes were matched by commensurate elevations in plasma cGMP levels (P 0.01). Interestingly, infusion of GTN, an NO donor, significantly reduced plasma NOx (P < 0.001) and its urine elimination (P < 0.001) in patients with diabetes without reducing plasma cGMP levels (P 0.89). Cardiac surgery increased plasma insulin in patients with and without diabetes; this increase was delayed by the infusion of GTN, but it was not related to the changes in NO production. In conclusion, NO production during cardiac surgery is increased in patients with diabetes, and this elevation can be blunted by the infusion of GTN in a rapid and reversible manner

Meeting Report on the International Conference of ECMO-Life Support for Pakistan in 21st Century held May 11-12, 2017, Lahore

Extracorporeal membrane oxygenation support (ECMO) is indicated in severe heart or lung failure with 80 percent or more risk of mortality. In experienced centers, overall survival to discharge ranges from 40 percent in cardiac arrest with extracorporeal cardiopulmonary resuscitation (ECPR) to 70 percent for respiratory failure in adults. Overall survival in children is about 80 percent and newborns with severe lung injury can recover to normal function following prolonged ECMO support, thus, re-defining irreversible lung injury. In the future, ECMO will be automatically controlled with care out of the Intensive care units (ICU) or at home. The International Conference of ECMO-Life Support for Pakistan in 21st Century which was recently held in Lahore, Pakistan on May 11 - 12, 2017. It was to bring together the best of cardiothoracic and vascular surgeons, heart failure cardiologist, adult and pediatric intensivists, pulmonologists, anaesthetists, cardiovascular nurses, postgraduate trainees, para-medical staff, perfusionists, ambulance cardiac first responders and cardiovascular scientists for thought provoking evidence based discussions on the direction and flow of ECMO technology for Pakistan and the Developing World in the next decade. The aim of this conference was to share knowledge on ECMO technologies, advancements and their impact on the health capacity building

Website design: Technical, social and medical issues for self-reporting by elderly patients

There is growing interest in the use of the Internet for interacting with patients, both in terms of healthcare information provision and information gathering. In this paper we examine the issues in designing healthcare websites for elderly users. In particular this paper uses a year-long case study of the development of a web-based system for self-reporting of symptoms and quality of life with a view to examine the issues relating to website design for elderly users. The issues identified included the technical, social and medical aspects of website design for elderly users. The web-based system developed was based upon the EQ5D health-status questionnaire, a commonly used tool for patient self-reporting of quality of life, and the more specific CROQ (coronary revascularisation outcome questionnaire) questionnaire. Currently self-reporting is generally administered in the form of paper-based questionnaires to be completed in the out-patient clinic, or at home. There are a variety of issues relating to elderly users that imply that websites for elderly patients may involve different design considerations to other types of websites

An Intervention for Pulmonary Rehabilitators to Develop a Social Identity for Patients Attending Exercise Rehabilitation: A Feasibility and Pilot Randomised Control Trial Protocol

Background: Chronic obstructive pulmonary disease (COPD) is a degenerative condition that can impair health related quality of life (HRQoL). A number of self-management interventions, employing a variety of behavioural change techniques (BCTs), have been adopted to improve HRQoL for COPD patients. However, a lack of attention has been given to group management interventions with an emphasis on incorporating BCTs into rehabilitators practice. This study aims to pilot and feasibly explore a social identity group- management intervention, delivered by COPD rehabilitation staff to patients attending exercise pulmonary rehabilitation. Doing so will help inform the plausibility of the intervention before conducting a full trial to evaluate its effectiveness to improve HRQoL. Methods: This is a two center, randomized cross-over controlled trial. Two pulmonary rehabilitation centres based in the UK will be randomly allocated to two treatment arms (standard care and intervention). Outcome measurements relating to HRQoL and social identity will be completed pre and post exercise rehabilitation. Focus group interviews will be conducted at the end of exercise rehabilitation to capture participants’ contextualised experiences of the intervention. COPD rehabilitators will undertake semi-structured interviews at the end of the trial to garner their holistic perspectives of intervention fidelity and implementation. Discussion: This is the first study to adopt a social identity approach to develop a rehabilitator-led, group management intervention for COPD patients attending exercise pulmonary rehabilitation. The results of this study will provide evidence for the feasibility and sample size requirements to inform a larger study, which can ascertain the intervention’s effectiveness for improving HRQoL for COPD patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02288039. Date 31st October 2014

Evaluating the Performance of Cooperative Merging Assistance System for Aging Drivers

Freeway merging maneuvers demand considerable attention by drivers and are among the more complex operations drivers must perform on freeways. Aging drivers, a growing population in the United States, face added challenges when merging. This study utilized Vissim models created in a previous study that modeled the behavior of aging drivers during freeway merging. An algorithm for Cooperative Merging Assistance System (CMAS) that utilizes Connected Vehicle (CV) technology was developed in this study. The Vissim models were created for two interchanges on I-75 in Fort Myers, Florida, each with different geometric characteristics. Acceleration lane lengths of 1000ft and 1500ft were analyzed in this study, and the CV environment was created in Vissim through the Component Object Model (COM) Interface. A sensitivity analysis was conducted by varying CV penetration rates, composition of aging on-ramp drivers, and mainline and on-ramp traffic flows to analyze the effects of CV technology under different levels of service (LOSs). Merging location, merging speed and vehicle interaction states (braking for lane change, emergency stop and cooperative braking) together with deceleration rate were the measures of effectiveness (MOEs) considered. Findings showed the number of aging drivers merging late onto the freeway can be decreased by up to 60.0% when CMAS was employed, while there was no significant change in merging speed at 95% confidence level when CMAS was employed. Furthermore, the results showed that CMAS reduced the percentages of aging drivers braking for lane change or emergency stop and also hard braking by up to 100% for low traffic conditions (LOS A and B). A maximum reduction of 82.2% was observed for cooperative braking of mainline vehicles when CMAS was employed. The reductions in interaction states were significant at 95% confidence level according to Mann-Kendall trend test