The influence of socio-demographic and clinical factors on sick leave and return to work after open-heart surgery: a nationwide registry-based cohort study.

AIMS: To estimate sick leave (SL) duration after first-time elective open-heart surgery and identify factors contributing to increased SL. METHODS AND RESULTS: A retrospective nationwide cohort study combined data from the Norwegian Register for Cardiac Surgery and SL data from the Norwegian Labour and Welfare Administrations. All able-bodied adults who underwent first-time elective open-heart surgery in Norway between 2012 and 2021 were followed until one year after surgery. The impact of socio-demographic and clinical factors on SL after surgery was analysed using logistic regression and odds ratios. Of 5456 patients, 1643 (30.1%), 1798 (33.0%), 971 (17.8%), 1035 (18.9%), and 9 (0.2%) had SL of <3, 3-6, 6-9, and 9-12 months, and one year, respectively. SL > 6 months was associated with female gender, primary education only, and average annual income. Postoperative stroke, postoperative renal failure, New York Heart Association Functional Classification system (NYHA) score > 3, earlier myocardial infarction, and diabetes mellitus increased the odds of SL > 6 months. CONCLUSION: This study demonstrates that socio-demographic and clinical factors impact SL after first-time elective open-heart surgery. Patients who experience a stroke or develop renal failure after surgery have the highest odds of SL > 6 months. Females and patients with low education levels, earlier myocardial infarction, or NYHA scores III-IV have a twofold chance of SL > 6 months. The findings allow for future investigations of pre- and post-surgery interventions that can most effectively reduce SL and aid return to work.

Return to work after coronary artery bypass grafting and aortic valve replacement surgery: A scoping review.

BACKGROUND: Coronary artery bypass grafting surgery and aortic valve replacement surgery are essential treatment options for people suffering from angina pectoris or aortic valve disease. Surgery aims to prolong life expectancy, improve quality of life, and facilitate participation in society for the individuals afflicted. The aim of this review was to explore the literature on work participation in patients following coronary artery bypass grafting or aortic valve replacement surgery, and to identify demographic and clinical characteristics associated with returning to work. METHODS: A scoping review framework of Arksey and O'Malley was chosen. Four electronic databases: Medline, CINAHL, Embase, and Google Scholar were searched for studies in English, Swedish, Danish or Norwegian between January 1988 and January 2020. A blinded selection of articles was performed. The data were then charted and summarized by descriptive numerical analyses and categorized into themes. RESULTS: Forty-five out of 432 articles were included in the final full-text analysis. Absence from work following coronary artery bypass graft grafting or aortic valve replacement surgery lasted on average 30 weeks, whereas 34% of the patients never returned to work. Being female, suffering from pre-existing depression, having limited secondary education, or low income were associated with decreased return to work rates. Previous employment was a decisive factor for returning to work after surgery. Data on return to work after aortic valve replacement were scarce. CONCLUSIONS: A significant number of patients never return to work following coronary artery bypass grafting or aortic valve surgery, and the time interval until work return is longer than expected. Failure to resume work represents a threat to the patients' finances and quality of life. Nurses are in a unique position to assess work-related issues and have an active part in the multi-disciplinary facilitation of tailored occupational counselling after cardiac surgery.

The Psychological and HRQoL related Aftermaths of Extra Corporeal Membrane Oxygenation Treatment: A Cross-Sectional Study.

OBJECTIVES: To assess symptoms of post-traumatic stress disorder, anxiety, depression and health related quality of life in a sample of adult patients treated with veno-arterial extracorporeal membrane oxygenation. DESIGN AND SETTING: This is a cross-sectional study. The population were all patients discharged (2008-2018) from a thoracic surgical intensive ward at a tertiary university hospital in Norway. A sample of 20 patients was recruited. MAIN OUTCOME MEASURES: Symptoms of post-traumatic stress disorder were assessed using Impact of Events Scale-Revised, while symptoms of depression and anxiety were assessed using Hospital Anxiety and Depression Scale. RAND 36-Item Short Form Health Survey was applied to measure health-related quality of life. RESULTS: Symptoms of post-traumatic stress disorder were reported by 40% of the participants. Twenty percent reported symptoms of depression and anxiety. Compared to the general population, participants reported poorer health-related quality of life on all domains, and significantly worse on the domains physical function, general health and social function. CONCLUSION: Patients in our study reported symptoms of post-traumatic stress disorder, anxiety, depression and impaired health-related quality of life following treatment with veno-arterial extra corporeal membrane oxygenation. Addressing possible emotional and psychological distress could represent a potential major improvement in health care provided to this group. Further research is needed to incorporate prophylactic methods, such as identifying vulnerable patients and implement corresponding interventions, into clinical practice.

Outcomes of patients suffering unwitnessed hypothermic cardiac arrest rewarmed with extracorporeal life support: A systematic review.

Prolonged cardiac arrest (CA) may lead to neurologic deficit in survivors. Good outcome is especially rare when CA was unwitnessed. However, accidental hypothermia is a very specific cause of CA. Our goal was to describe the outcomes of patients who suffered from unwitnessed hypothermic cardiac arrest (UHCA) supported with Extracorporeal Life Support (ECLS). We included consecutive patients' cohorts identified by systematic literature review concerning patients suffering from UHCA and rewarmed with ECLS. Patients were divided into four subgroups regarding the mechanism of cooling, namely: air exposure; immersion; submersion; and avalanche. A statistical analysis was performed in order to identify the clinical parameters associated with good outcome (survival and absence of neurologic impairment). A total of 221 patients were included into the study. The overall survival rate was 27%. Most of the survivors (83%), had no neurologic deficit. Asystole was the presenting CA rhythm in 48% survivors, of which 79% survived with good neurologic outcome. Variables associated with survival included the following: female gender (P < .001); low core temperature (P = .005); non-asphyxia-related mechanism of cooling (P < .001); pulseless electrical activity as an initial rhythm (P < .001); high blood pH (P < .001); low lactate levels (P = .003); low serum potassium concentration (P < .001); and short resuscitation duration (P = .004). Severely hypothermic patients with unwitnessed CA may survive with good neurologic outcome, including those presenting as asystole. The initial blood pH, potassium, and lactate concentration may help predict outcome in hypothermic CA.

An experimental study on intraoperative recovery of recurrent laryngeal nerve function.

OBJECTIVE: If bilateral thyroid surgery is planned and staged thyroidectomy considered in case of loss of neuromonitoring signal (LOS), a waiting time of 20 minutes is suggested for evaluation of early nerve recovery. This recommendation is based on clinical observations and has not been thoroughly validated experimentally. METHODS: Sixteen pigs were randomly studied, and electromyogram (EMG) was continuously recorded during traction injury until an amplitude decrease of 70% from baseline (BL) (16 nerves) or LOS (16 nerves), and further during 40-minute recovery time. At the end of the experiments, vocal cord twitch was evaluated by video-laryngoscopy. RESULTS: In the 70% group, 8 of 16 nerves recovered to or above an amplitude of 50% of baseline after 20 minutes and finally one more after 40 minutes. In the LOS group, only one nerve showed recovery after 20 minutes and one more after 40 minutes. Video-laryngoscopy revealed good or strong vocal cord twitches, in 10 of 14 nerves in the 70% group and in only 2 of 14 nerves in the LOS group. CONCLUSIONS: The overall intraoperative recovery was low after LOS. Even after 70% amplitude depression, only half of the nerves showed recovery to amplitudes ≥50% of BL. Nerve recovery is dynamic, and a waiting time of 20 minutes seems appropriate for the identification of early nerve recovery before decisions are taken to continue or terminate surgery. The final EMG amplitude was not always well correlated with estimated vocal cord twitch, evaluated by video-laryngoscopy. This observation needs further investigation.

Injury mechanisms and electromyographic changes after injury of the recurrent laryngeal nerve: Experiments in a porcine model.

BACKGROUND: Recurrent laryngeal nerve (RLN) injury during surgery may reveal differences in electromyographic (EMG) changes after sustained compression or traction. METHODS: In 20 pigs with the NIM-FLEX EMG-endotracheal tube, EMG was recorded at baseline, during sustained RLN compression, or traction until 70% amplitude decrease and during 30 minutes of recovery. RESULTS: Seventy percent amplitude decrease from baseline was reached after 110 ± 98 seconds (compression group) and 2034 ± 2108 seconds (traction group). Traction induced a pronounced latency increase, peaking at 122 ± 8% in contrast to compression with 106 ± 5% (P < .001). The EMG amplitude recovery to ≥50% of baseline failed in 7 nerves after compression and 8 nerves after traction. CONCLUSION: Compression caused a fast decrease of EMG amplitude with minor effects on latency. In contrast, RLN traction showed early and significant latency increase preceding a delayed amplitude decrease. Recovery rate of the EMG signals were similar in both groups.

Is the use of hydroxyethyl starch as priming solution during cardiac surgery advisable? A randomized, single-center trial.

INTRODUCTION: The use of cardiopulmonary bypass (CPB) leads to increased fluid filtration and edema. The use of artificial colloids to counteract fluid extravasation during cardiac surgery is controversial. Beneficial effects on global fluid loading, leading to better cardiac performance and hemodynamics, have been claimed. However, renal function and coagulation may be adversely affected, with unfavorable impact on outcome following cardiac surgery. METHODS: Forty patients were randomly allocated to study groups receiving either acetated Ringer's solution (CT group) or hydroxyethyl starch (HES group, Tetraspan®) as CPB priming solution. Fluid balance, bleeding and hemodynamics, including cardiac output, were followed postoperatively. The occurrence of acute kidney injury was closely registered. RESULTS: Two patients were excluded from further analyzes due to surgical complications. Fluid accumulation was attenuated in the HES group (3374 (883) ml) compared with the CT group (4328 (1469) ml) (p=0.024). The reduced perioperative fluid accumulation was accompanied by an increased cardiac index immediately after surgery (2.7 (0.4) L/min/m2 in the HES group and 2.1 (0.3) L/min/m2 in the CT group (p<0.001)). No increase in bleeding could be demonstrated in the HES group. Three patients, all of them in the HES group, experienced acute kidney injury postoperatively. CONCLUSIONS: CPB priming with HES solution lowers fluid loading during bypass and improves cardiac function in the early postoperative period. The manifestation of acute kidney injury exclusively in the HES group of patients raises doubts about the use of HES products in conjunction with cardiac surgery. ( https://clinicaltrials.gov/ct2/show/NCT01511120 ).

Microvascular fluid exchange during CPB with deep hypothermia circulatory arrest or low flow.

OBJECTIVE: Use of deep hypothermic low-flow (DHLF) cardiopulmonary bypass (CPB) has been associated with higher fluid loading than the use of deep hypothermia circulatory arrest (DHCA). We evaluated whether these perfusion strategies influenced fluid extravasation rates and edema generation differently per-operatively. MATERIALS AND METHODS: Twelve anesthetized pigs, randomly allocated to DHLF (n = 6) or DHCA (n = 6), underwent 2.5 hours CPB with cooling to 20°C for 30 minutes (min), followed by 30 min arrested circulation (DHCA) or 30 min low-flow circulation (DHLF) before 90 min rewarming to normothermia. Perfusion of tissues, fluid requirements, plasma volumes, colloid osmotic pressures and total tissue water contents were recorded and fluid extravasation rates calculated. During the experiments, cerebral microdialysis was performed in both groups. RESULTS: Microvascular fluid homeostasis was similar in both groups, with no between-group differences, reflected by similar fluid extravasation rates, plasma colloid osmotic pressures and total tissue water contents. Although extravasation rates increased dramatically from 0.10 (0.11) ml/kg/min (mean with standard deviation in parentheses) and 0.16 (0.02) ml/kg/min to 1.28 (0.58) ml/kg/min and 1.06 (0.41) ml/kg/min (DHCA and DHLF, respectively) after the initiation of CPB, fluid filtrations during both cardiac arrest and low flow were modest and close to baseline values. Cerebral microdialysis indicated anaerobic metabolism and ischemic brain injury in the DHCA group. CONCLUSION: No differences in microvascular fluid exchange could be demonstrated as a direct effect of DHCA compared with DHLF. Thirty minutes of DHCA was associated with anaerobic cerebral metabolism and possible brain injury.

Does Roller Pump-Induced Pulsatile CPB Perfusion Affect Microvascular Fluid Shifts and Tissue Perfusion?

BACKGROUND: Pulsatile versus nonpulsatile cardiopulmonary bypass (CPB) perfusion remains debated. Beneficial effects on tissue perfusion, inflammation, and microvascular fluid exchange have been linked to pulsatile perfusion by some investigators and denied by others. This study evaluated fluid extravasation and tissue perfusion during nonpulsatile or pulsatile roller pump-induced CPB perfusion. METHODS: Fourteen pigs underwent roller pump-induced pulsatile (n = 7) or nonpulsatile CPB perfusion (n = 7) for 90 minutes. Fluid input/losses, colloid osmotic pressures (plasma/interstitium), hematocrit, serum electrolytes, serum proteins, tissue perfusion, and total tissue water content were measured, and plasma volume and fluid extravasation were calculated. RESULTS: Fluid additions/losses, plasma volume, and fluid extravasation changed similarly in both groups during CPB with no between-group differences. Neither was between-group differences observed for tissue perfusion and total tissue water content, with one exception. Total tissue water content of the right (3.92 ± 0.26 versus 4.32 ± 0.28 g/g dry weight) and left ventricle (4.02 ± 0.25 versus 4.33 ± 0.24 g/g dry weight) was lowered in the pulsatile group. CONCLUSIONS: No important differences were found between pulsatile and nonpulsatile CPB perfusion for microvascular fluid balance and tissue perfusion.

Lymphotoxin-alpha contributes to lymphangiogenesis.

Lymphotoxin-α (LTα), lymphotoxin-ß (LTß), and tumor necrosis factor-α (TNFα) are inflammatory mediators that play crucial roles in lymphoid organ development. We demonstrate here that LTα also contributes to the function of lymphatic vessels and to lymphangiogenesis during inflammation. LTα(-/-) mice exhibited reduced lymph flow velocities and increased interstitial fluid pressure. Airways of LTß(-/-) mice infected with Mycoplasma pulmonis had significantly more lymphangiogenesis than wild type (WT) or LTα(-/-) mice, as did the skin draining immunization sites of LTß(-/-) mice. Macrophages, B cells, and T cells, known sources of LT and TNFα, were apparent in the skin surrounding the immunization sites as were LTα, LTß, and TNFα mRNAs. Ectopic expression of LTα led to the development of LYVE-1 and Prox1-positive lymphatic vessels within tertiary lymphoid organs (TLOs). Quantification of pancreatic lymphatic vessel density in RIPLTαLTß(-/-) and WT mice revealed that LTα was sufficient for inducing lymphangiogenesis and that LTß was not required for this process. Kidneys of inducible LTα transgenic mice developed lymphatic vessels before the appearance of obvious TLOs. These data indicate that LTα plays a significant role in lymphatic vessel function and in inflammation-associated lymphangiogenesis.

Predominance of Mycobacterium tuberculosis EAI and Beijing lineages in Yangon, Myanmar.

Isolates of the Mycobacterium tuberculosis Beijing lineage are associated with high rates of transmission, hypervirulence and drug resistance. The Beijing lineage has been shown to dominate the tuberculosis (TB) epidemic in East Asia; however, the diversity and frequency of M. tuberculosis genotypes from Myanmar are unknown. We present the first comprehensive study describing the M. tuberculosis isolates circulating in Yangon, Myanmar. Thus, 310 isolates from pulmonary TB patients from Yangon, Myanmar, were genotyped by spoligotyping and IS6110-based restriction fragment length polymorphism analysis (IS6110 RFLP). The most frequent lineages observed were the East African-Indian (EAI; 48.4%; n = 150) and Beijing (31.9%; n = 99) lineages. Isolates belonging to the most frequent shared types (STs), ST1 (n = 98; Beijing), ST292 (n = 28; EAI), and ST89 (n = 11; EAI), had >or=75% similarity in their IS6110 patterns. Five of 11 Beijing isolates comprising five clusters with identical IS6110 RFLP patterns could be discriminated by mycobacterial interspersed repetitive-unit-variable-number tandem-repeat (MIRU-VNTR) analysis. Of the 150 EAI isolates, 40 isolates (26.7%) had only one IS6110 copy, and 17 of these isolates could be discriminated by MIRU-VNTR analysis. The findings from this study suggest that although there is a predominance of the ancient EAI lineage in Yangon, the TB epidemic in Yangon is driven by clonal expansion of the ST1 genotype. The Beijing lineage isolates (21.4%) were more likely (P = 0.009) than EAI lineage isolates to be multidrug resistant (MDR) (1.3%; odds ratio, 3.2, adjusted for the patients' history of exposure to anti-TB drugs), suggesting that the spread of MDR Beijing isolates is a major problem in Yangon.