Does Fibre-fix provided to people with irritable bowel syndrome who are consuming a low FODMAP diet improve their gut health, gut microbiome, sleep and mental health? A double-blinded, randomised controlled trial.

INTRODUCTION: A diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) is an effective way to reduce gut symptoms in people with irritable bowel syndrome (IBS). This diet reduces the intake of fermentable fibres, leading to changes of the gut microbiota and insufficient fermentation in the large bowel, resulting in reduced production of short-chain fatty acids (SCFAs), such as butyrate, which has unfavourable implications for gut health, sleep and mental health. This study will examine the effect of Fibre-fix, a supplement containing a mix of dietary fibres, on the human gut microbiome composition, fermentative capacity, sleep, quality of life (QOL) and mental health of people with IBS who consume a low FODMAP diet (LFD). METHODS AND ANALYSIS: A randomised, double-blind, placebo-controlled, study design is proposed to examine whether Fibre-fix added to an existing LFD may help modulate gastrointestinal function, improve markers of sleep, mental health and promote QOL in patients with IBS. Participants will provide stool and blood samples, daily bowel symptoms diaries and 3-day diet records. Additionally, they will complete validated questionnaires relating to FODMAP intake, sleep, mental health and QOL before and after a 3-week intervention. Gut health will be assessed via faecal microbiome composition, faecal pH and SCFA levels. Alteration of sleep will be recorded using an actigraphy device worn by all participants over the whole study. Multivariate analysis will be used to examine the gut microbiome and repeated measures Analysis of variance (ANOVA) will be used for dependent variables from questionnaires related to bowel symptoms, stool type, sleep, mental health and QOL to assess the differences between intervention and control groups after adjustment for confounding variables. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Human Research Ethics Committee of Edith Cowan University (2019-00619-YAN). Results will be disseminated in peer-review journal publications, and conference presentations. Participants will be provided with a summary of findings once the study is completed. If Fibre-fix is shown to result in favourable changes in gut microbial composition, SCFA production, sleep and mental well-being without exacerbating symptoms, this will provide additional dietary management options for those with IBS following an LFD. TRIAL REGISTRATION NUMBER: ACTRN12620000032954.

A Multidisciplinary Protocol-Driven Approach to Improve Extubation Times After Cardiac Surgery.

BACKGROUND: Prolonged intubation after cardiac surgery is associated with significant morbidity. A fast-track extubation protocol primarily driven by bedside providers was instituted for all postoperative cardiac surgery patients to facilitate safe and expeditious extubation. METHODS: A retrospective review of 1,581 cardiac surgery patients over an 8-year period was performed. Before 2011, nonprotocolized standard perioperative management was utilized (n = 807). From 2011 onward, a fast-track extubation (FTE) protocol directed by bedside providers was instituted (n = 774). Postoperatively, patients were placed on pressure-regulated volume control and titrated down to minimal support to maintain peripheral capillary oxygen saturation greater than 94%. For patients deemed ready for weaning (no evidence of hypoxia, hemodynamic instability, and so forth), a 30-minute continuous positive airway pressure trial was performed. Patients meeting all neurologic, respiratory, and cardiovascular criteria were extubated. The impact of the FTE algorithm on timely extubation, clinical outcomes, and safety was assessed. RESULTS: Baseline preoperative and intraoperative characteristics were similar between pre-FTE and FTE groups. Before instituting the FTE protocol, the rate of early extubation (less than 6 hours) was 43.7%, and increased to 64.1% during the FTE era (p < 0.001). Median time to extubation was also found to be significantly decreased: 295 minutes (interquartile range: 288) versus 385 minutes (interquartile range: 362, p = 0.041). There was no statistically significant difference in reintubation rates or 30-day mortality. CONCLUSIONS: The institution of a bedside provider-directed FTE pathway reduced overall intubation times and increased the rate of early extubation, without an increase in reintubation or mortality. This program-wide multidisciplinary approach appears to promote safe and expeditious extubation of cardiac surgery patients.

Readmissions after cardiac surgery: experience of the National Institutes of Health/Canadian Institutes of Health research cardiothoracic surgical trials network.

BACKGROUND: Readmissions are a common problem in cardiac surgery. The goal of this study was to examine the frequency, timing, and associated risk factors for readmission after cardiac operations. METHODS: A 10-center cohort study prospectively enrolled 5,158 adult cardiac surgical patients (5,059 included in analysis) to assess risk factors for infection after cardiac operations. Data were also collected on all-cause readmissions occurring within 65 days after the operation. Major outcomes included the readmission rate stratified by procedure type, cause of readmission, length of readmission stay, and discharge disposition after readmission. Multivariable Cox regression was used to determine risk factors for time to first readmission. RESULTS: The overall rate of readmission was 18.7% (number of readmissions, 945). When stratified by the most common procedure type, readmission rates were isolated coronary artery bypass grafting, 14.9% (n = 248); isolated valve, 18.3% (n = 337); and coronary artery bypass grafting plus valve, 25.0% (n = 169). The three most common causes of first readmission within 30 days were infection (17.1% [n = 115]), arrhythmia (17.1% [n = 115]), and volume overload (13.5% [n = 91]). More first readmissions occurred within 30 days (80.6% [n = 672]) than after 30 days (19.4% [n = 162]), and 50% of patients were readmitted within 22 days from the index operation. The median length of stay during the first readmission was 5 days. Discharge in 15.8% of readmitted patients (n = 128) was to a location other than home. Baseline patient characteristics associated with readmission included female gender, diabetes mellitus on medication, chronic obstructive pulmonary disease, elevated creatinine, lower hemoglobin, and longer operation time. More complex surgical procedures were associated with an increased risk of readmission compared with the coronary artery bypass grafting group. CONCLUSIONS: Nearly 1 of 5 patients who undergo cardiac operations require readmission, an outcome with significant health and economic implications. Management practices to avert in-hospital infections, reduce postoperative arrhythmias, and avoid volume overload offer important targets for quality improvement.

Endothelial progenitor cell mobilization and increased intravascular nitric oxide in patients undergoing cardiac rehabilitation.

PURPOSE: We investigated whether cardiac rehabilitation participation increases circulating endothelial progenitor cells (EPCs) and benefits vasculature in patients already on stable therapy previously shown to augment EPCs and improve endothelial function. METHODS: Forty-six of 50 patients with coronary artery disease completed a 36-session cardiac rehabilitation program: 45 were treated with HMG-CoA reductase inhibitor (statin) therapy > or = 1 month (average baseline low-density lipoprotein cholesterol = 81 mg/dL). Mononuclear cells isolated from blood were quantified for EPCs by flow cytometry (CD133/VEGFR-2 cells) and assayed in culture for EPC colony-forming units (CFUs). In 23 patients, EPCs were stained for annexin-V as a marker of apoptosis, and nitrite was measured in blood as an indicator of intravascular nitric oxide. RESULTS: Endothelial progenitor cells increased from 35 +/- 5 to 63 +/- 10 cells/mL, and EPC-CFUs increased from 0.9 +/- 0.2 to 3.1 +/- 0.6 per well (both P < .01), but 11 patients had no increase in either measure. Those patients whose EPCs increased from baseline showed significant increases in nitrite and reduction in annexin-V staining (both P < .01) versus no change in patients without increase in EPCs. Over the course of the program, EPCs increased prior to increase in nitrite in the blood. CONCLUSIONS: Cardiac rehabilitation in patients receiving stable statin therapy and with low-density lipoprotein cholesterol at goal increases EPC number, EPC survival, and endothelial differentiation potential, associated with increased nitric oxide in the blood. Although this response was observed in most patients, a significant minority showed neither EPC mobilization nor increased nitric oxide in the blood.

Long-term safety of cardiac magnetic resonance imaging performed in the first few days after bare-metal stent implantation.

PURPOSE: To investigate the long-term safety of cardiac magnetic resonance imaging (CMR) performed one to seven days after coronary artery stent (bare metal) implantation. MATERIALS AND METHODS: We analyzed 119 consecutive patients with acute myocardial infarction (MI) who underwent emergency coronary stent implantation with a bare-metal stent. CMR using a 1.5T scanner was performed on 51 patients (42.9%) at a mean of 2.7+/-3.1 days after stent implantation (CMR+ group), and the remaining 68 patients (57.1%) served as controls (CMR- group). The patients were followed up to six months for major adverse cardiac events. RESULTS: The average stent size was 3.3+/-0.5x18.4+/-6.7 mm, and 86% of the stents were made of 316L stainless steel. There were no significant differences between the CMR+ and CMR- groups in terms of infarct features, angiographic findings, or stent characteristics. Over a mean follow-up of 4.4+/-2.1 months, 12 patients (10.1%) had 16 events (13.4%). Two patients had adverse events after early MRI scan (4.3%), a rate that is lower than the event rate in the patients who did not undergo MRI (16%, P=0.04), and one of the two events was clearly not MRI related. CONCLUSION: CMR on a 1.5T scanner can be safely performed within one to seven days after coronary bare-metal stent implantation and is not associated with an increased risk of adverse clinical cardiac outcomes. In the light of accumulating data, the guidelines by stent manufacturers should be revised.