Acute coronary occlusion after surgical replacement of the aortic valve treated with emergency off-pump coronary artery bypass grafting.

Acute coronary occlusion after surgical replacement of the aortic valve is a rare but potentially fatal event. Due to its rarity, there is no univocal treatment with the percutaneous approach being the most commonly used for its promptness and ease of use. Only a few cases have been treated with coronary artery bypass grafting (CABG) and, to the best of our knowledge, none has been reported with the use of off-pump CABG (OPCABG). Here we describe the case of acute coronary occlusion of the circumflex artery immediately after surgical replacement of the aortic valve in a 79-year-old patient. The occlusion was promptly diagnosed and treated with interval emergency balloon angioplasty followed by OPCABG of the circumflex artery. The patient made a full recovery and was discharged home 12 days after the surgery.

Impact of Preoperative Atrial Fibrillation on In-Hospital Outcomes of Coronary Artery Bypass Grafting.

Perioperative atrial fibrillation (AF) is associated with increased mortality, morbidity, and excess healthcare costs. The objective of our study was to assess if preoperative AF in patients undergoing coronary artery bypass grafting is a predictor of operative mortality, postoperative stroke, and need for postoperative dialysis by interrogating a large registry database. We included all isolated procedures performed between February 1996 and March 2019. We used a generalized linear mixed model to assess the effect of preoperative AF on mortality stroke and the need for postoperative dialysis after adjusting for the relevant confounders derived from EuroSCORE 2. Confounders considered included age, gender, neurological dysfunction, renal dysfunction, recent myocardial infarction, pulmonary disease, unstable angina, NYHA class, pulmonary hypertension, diabetes on insulin and peripheral vascular disease, and urgency of the operation. We treated the hospital and operating consultant as random effect variables. We also performed LV function subgroup analyses to assess the effect of preoperative AF on the outcomes of interest. The incidence of pre-existent AF in the cohort of patients we analyzed (N = 356,040 patients) was 3.5% (N = 12,664). In the unadjusted baseline characteristics, preoperative AF patients had more associated comorbidities. After adjustment, preoperative AF remained a significant predictor of increased mortality (odds ratio [OR]: 1.63, confidence interval [CI] 1.48-1.79, p < 0.001), stroke (OR: 1.33, CI 1.16-1.54, p = 0.001), and need for renal dialysis (OR:1.61, CI 1.46-1.78, p < 0.001). Preoperative AF was a significant predictor of adverse outcomes in patients with moderate and good LV function but not in patients with poor LV function (EF <30%). Our study suggests that preoperative AF is associated with an increased risk for perioperative mortality and stroke in patients undergoing coronary artery bypass grafting.

Antimicrobial prophylaxis in adult cardiac surgery in the United Kingdom and Republic of Ireland.

BACKGROUND: Deep sternal wound infections are a financially costly complication of cardiac surgery with serious implications for patient morbidity and mortality. Prophylactic antimicrobials have been shown to reduce the incidence of infection significantly. In 2018, the European Association for CardioThoracic Surgery (EACTS) provided clear guidance advising that third-generation cephalosporins are the first-line prophylactic antimicrobial of choice for cardiac surgery via median sternotomy as a result of their broad spectrum of activity and association with reduced postoperative mortality. Despite this guidance, it was believed that UK practice differed from this as a consequence of national concerns surrounding cephalosporins use and Clostridioides difficile infection. METHODS: A survey was developed and distributed to all UK and Republic of Ireland (ROI) cardiac surgery centres in January 2019 to quantify this variation. RESULTS: Of the 38 centres, 34 responded. Variation existed between the antimicrobial agent used, as well as the dosage, frequency and duration of suggested regimens even among centres using the same antimicrobial agent. The most common antimicrobial prophylaxis prescribed was a combination of flucloxacillin and gentamicin (16, 47%). Followed by cefuroxime (6, 17.6%) and cefuroxime combined with a glycopeptide (4, 11.7%). In patients colonised with methicillin-resistant Staphylococcus aureus or those with penicillin allergy gentamicin combined with teicoplanin was most common (42% and 50%, respectively). DISCUSSION: This variation in antimicrobial agents and regimens may well contribute to the varying incidence of surgical site infection seen across the UK and ROI.

Best evidence topic: Can acute appendicitis manifest with normal inflammatory markers?

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: for patients with suspected acute appendicitis can normal inflammatory markers rule out the diagnosis? Altogether 151 papers were found using the search strategy reported below. Seven were identified to provide the best evidence to answer the question. The author, journal, date, and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. In conclusion, six out of seven papers are more in favour with the concept that normal inflammatory markers cannot effectively rule out the diagnosis of acute appendicitis.

Appendiceal phlegmon in adults: Do we know how to manage it yet?

A Best Evidence Topic in general surgery was written according to a structured protocol. The question addressed was 'Appendiceal phlegmon in adults: Do we know how to manage it yet?'. Altogether 217 papers were found on Ovid Embase and Medline, 334 on PubMed and 13 on the Cochrane database using the reported search. From the screened articles, 5 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that the best management method is conservative only treatment without interval appendicectomy. These patients must be followed up, including colonoscopy and/or CT imaging as indicated, to investigate for conditions such as inflammatory bowel disease or malignancy masquerading as appendicitis.

Early versus interval appendicectomy for localised perforated appendicitis in children: A best evidence review.

A best evidence topic in general surgery was written according to a structured protocol. The question addressed was whether early or interval appendicectomy provides a superior clinical outcome for children presenting with localised perforated appendix. Altogether 204 papers were found using the search strategy reported below; of which 5 were identified to provide the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We concluded that for children presenting with localised perforated appendix without abscess formation, early appendicectomy provides better clinical outcome in terms of lower complication and re-admission rate and shorter length of hospital stay.

Non-Instrumental Movement Inhibition (NIMI) Differentially Suppresses Head and Thigh Movements during Screenic Engagement: Dependence on Interaction.

BACKGROUND: Estimating engagement levels from postural micromovements has been summarized by some researchers as: increased proximity to the screen is a marker for engagement, while increased postural movement is a signal for disengagement or negative affect. However, these findings are inconclusive: the movement hypothesis challenges other findings of dyadic interaction in humans, and experiments on the positional hypothesis diverge from it. HYPOTHESES: (1) Under controlled conditions, adding a relevant visual stimulus to an auditory stimulus will preferentially result in Non-Instrumental Movement Inhibition (NIMI) of the head. (2) When instrumental movements are eliminated and computer-interaction rate is held constant, for two identically-structured stimuli, cognitive engagement (i.e., interest) will result in measurable NIMI of the body generally. METHODS: Twenty-seven healthy participants were seated in front of a computer monitor and speakers. Discrete 3-min stimuli were presented with interactions mediated via a handheld trackball without any keyboard, to minimize instrumental movements of the participant's body. Music videos and audio-only music were used to test hypothesis (1). Time-sensitive, highly interactive stimuli were used to test hypothesis (2). Subjective responses were assessed via visual analog scales. The computer users' movements were quantified using video motion tracking from the lateral aspect. Repeated measures ANOVAs with Tukey post hoc comparisons were performed. RESULTS: For two equivalently-engaging music videos, eliminating the visual content elicited significantly increased non-instrumental movements of the head (while also decreasing subjective engagement); a highly engaging user-selected piece of favorite music led to further increased non-instrumental movement. For two comparable reading tasks, the more engaging reading significantly inhibited (42%) movement of the head and thigh; however, when a highly engaging video game was compared to the boring reading, even though the reading task and the game had similar levels of interaction (trackball clicks), only thigh movement was significantly inhibited, not head movement. CONCLUSIONS: NIMI can be elicited by adding a relevant visual accompaniment to an audio-only stimulus or by making a stimulus cognitively engaging. However, these results presume that all other factors are held constant, because total movement rates can be affected by cognitive engagement, instrumental movements, visual requirements, and the time-sensitivity of the stimulus.