A case report of coexisting multinodular goiter with carotid body tumor.

INTRODUCTION: Carotid body tumor (CBT), a neuroendocrine neoplasm, and benign multinodular goiter (BMNG) are distinct pathologies affecting the neck region. Although rare, they can occur concurrently. This case contributes to the limited evidence regarding the association between these distinct pathologies and their operative management. CASE PRESENTATION: The patient was a 45-year-old female with a palpable mass on the right side of her neck. She was diagnosed with Shamblin type III non-secretory CBT alongside BMNG. The surgical intervention included resection of the CBT, carotid artery bypass, and Dunhill thyroidectomy. DISCUSSION: This case is the third reported instance of coexisting CBT and BMNG. Their causative relationship is evident in the literature without a clear explanation of the underlying mechanism. Both conditions are treated surgically. Dunhill thyroidectomy for BMNG is a safer option, offering more flexibility and advantages over other thyroidectomies. CONCLUSION: This case highlights the complexity of managing such dual pathologies and may provide further evidence of their association.

Schizosaccharomyces pombe Grx4, Fep1, and Php4: In silico analysis and expression response to different iron concentrations.

Due to iron's essential role in cellular metabolism, most organisms must maintain their homeostasis. In this regard, the fission yeast Schizosaccharomyces pombe (sp) uses two transcription factors to regulate intracellular iron levels: spFep1 under iron-rich conditions and spPhp4 under iron-deficient conditions, which are controlled by spGrx4. However, bioinformatics analysis to understand the role of the spGrx4/spFep1/spPhp4 axis in maintaining iron homeostasis in S. pombe is still lacking. Our study aimed to perform bioinformatics analysis on S. pombe proteins and their sequence homologs in Aspergillus flavus (af), Saccharomyces cerevisiae (sc), and Homo sapiens (hs) to understand the role of spGrx4, spFep1, and spPhp4 in maintaining iron homeostasis. The three genes' expression patterns were also examined at various iron concentrations. A multiple sequence alignment analysis of spGrx4 and its sequence homologs revealed a conserved cysteine residue in each PF00085 domain. Blast results showed that hsGLRX3 is most similar to spGrx4. In addition, spFep1 is most closely related in sequence to scDal80, whereas scHap4 is most similar to spFep1. We also found two highly conserved motifs in spFep1 and its sequence homologs that are significant for iron transport systems because they contain residues involved in iron homeostasis. The scHap4 is most similar to spPhp4. Using STRING to analyze protein-protein interactions, we found that spGrx4 interacts strongly with spPhp4 and spFep1. Furthermore, spGrx4, spPhp4, and spFep1 interact with spPhp2, spPhp3, and spPhp5, indicating that the three proteins play cooperative roles in iron homeostasis. At the highest level of Fe, spgrx4 had the highest expression, followed by spfep1, while spphp4 had the lowest expression; a contrast occurred at the lowest level of Fe, where spgrx4 expression remained constant. Our findings support the notion that organisms develop diverse strategies to maintain iron homeostasis.

Screening a novel six critical gene-based system of diagnostic and prognostic biomarkers in prostate adenocarcinoma patients with different clinical variables.

The mechanisms behind prostate adenocarcinoma (PRAD) pathogenicity remain to be understood due to tumor heterogeneity. In the current study, we identified by microarray technology six eligible real hub genes from already identified hub genes through a systematic in silico approach that could be useful to lower the heterogenetic-specific barriers in PRAD patients for diagnosis, prognosis, and treatment. For this purpose, microarray technology-based, already-identified PRAD-associated hub genes were initially explored through extensive literature mining; then, a protein-protein interaction (PPI) network construction of those hub genes and its analysis helped us to identify six most critical genes (real hub genes). Various online available expression databases were then used to explore the tumor driving, diagnostic, and prognostic roles of real hub genes in PRAD patients with different clinicopathologic variables. In total, 124 hub genes were extracted from the literature, and among those genes, six, including CDC20, HMMR, AURKA, CDK1, ASF1B, and CCNB1 were identified as real hub genes by the degree method. Further expression analysis revealed the significant up-regulation of real hub genes in PRAD patients of different races, age groups, and nodal metastasis status relative to controls. Moreover, through correlational analyses, different valuable correlations between treal hub genes expression and different other data (promoter methylation status, genetic alterations, overall survival (OS), tumor purity, CD4+ T, CD8+ T immune cells infiltration, and different other mutant genes and a few more) across PRAD samples were also documented. Ultimately, from this study, a few important transcription factors (TFS), miRNAs, and chemotherapeutic drugs showing a great therapeutic potential were also identified. In conclusion, we have discovered a set of six real hub genes that might be utilized as new biomarkers for lowering heterogenetic-specific barriers in PRAD patients for diagnosis, prognosis, and treatment.

Basis for using thioredoxin as an electron donor by Schizosaccharomyces pombe Gpx1 and Tpx1.

Glutathione (GSH) peroxidases (GPxs or GSHPx) and thioredoxin (Trx) peroxidases (TPxs) are two classes of peroxidases that catalyze the reduction of peroxides. GPxs and TPxs generally use GSH or Trx, respectively, to recycle the oxidized cysteine (Cys) residue in the protein. However, it is unclear why unlike human GPxs, the Schizosaccharomyces pombe Gpx1 (spGpx1) prefers Trx over GSH for recycling of the active-site peroxidatic Cys residue. Here, we compared spGpx1 and S. pombe Tpx1 (spTpx1) protein sequences with those of their respective homologs in Saccharomyces cerevisiae and humans. Our analysis revealed that like spTpx1, spGpx1 contains a pair of conserved Cys residues (Cys36 and Cys82). These two conserved Cys residues are named peroxidatic and resolving Cys residues, respectively, and are found only in GPxs and TPxs that prefer Trx as an electron donor. Our analysis suggested that Cys36 and Cys82 in spGpx1 are most likely to form a disulfide bond upon oxidation of Cys36. Molecular modelling predicted that a conformational change might be required for the formation of this disulfide bond. Evolutionary analysis suggested that fungal GPxs and TPxs are related by divergent evolution from a common ancestor. Our analyses support a prediction that while spGpx1 and spTpx1 are phylogenetically and functionally different, they evolved from a common ancestor and use a similar mechanism for recycling of the active-site peroxidatic Cys residue.

Transmural myocardial repair with engineered heart muscle in a rat model of heterotopic heart transplantation - A proof-of-concept study.

Engineered heart muscle (EHM) can be implanted epicardially to remuscularize the failing heart. In case of a severely scarred ventricle, excision of scar followed by transmural heart wall replacement may be a more desirable application. Accordingly, we tested the hypothesis that allograft (rat) and xenograft (human) EHM can also be administered as transmural heart wall replacement in a heterotopic, volume-loaded heart transplantation model. We first established a novel rat model model to test surgical transmural left heart wall repair. Subsequently and in continuation of our previous allograft studies, we tested outcome after implantation of contractile engineered heart muscle (EHM) and non-contractile engineered connective tissue (ECT) as well as engineered mesenchymal tissue (EMT) allografts as transmural heart wall replacement. Finally, proof-of-concept for the application of human EHM was obtained in an athymic nude rat model. Only in case of EHM implantation, remuscularization of the surgically created transmural defect was observed with palpable graft vascularization. Taken together, feasibility of transmural heart repair using bioengineered myocardial grafts could be demonstrated in a novel rat model of heterotopic heart transplantation.

Concomitant trans-sternal repair of Morgagni hernia and ventricular septal defect in a patient with Down syndrome: A case report.

INTRODUCTION: Morgagni hernia is a rare type of hernia occurring secondary to potential anterior-medial defects in the diaphragm. The association of the defect with congenital cardiac pathologies and Down syndrome are well known. The defect is repaired usually by trans-abdominal or transthoracic approaches. Trans-sternal repair of the hernia is preferred in patients undergoing concomitant open heart surgery. CASE PRESENTATION: A 2-year-old child with Down syndrome underwent concomitant repair of Morgagni hernia and closure of his ventricular septal defect under cardiopulmonary bypass. The hernia was corrected by the sternotomy approach, without opening the hernia content, before the correction of the cardiac pathology. The patient made an uneventful recovery and was discharged on the 4th postoperative day. DISCUSSION: Preoperative diagnosis of diaphragmatic hernia in congenital heart disease is important to decrease mortality rate. However, trans-sternal exposure of the defect is also possible, as in this case, in patients undergoing open heart surgery for congenital cardiac defects. The defect can be repaired by this approach, concomitantly with the cardiac anomaly, no need for an additional incision and without opening the hernia sac. CONCLUSION: Our experience, although very limited, in patients who are suffering from Morgagni hernia and concomitant congenital heart defects shows that simultaneous repair of Morgagni hernia through midline sternotomy prior to cardiac procedure is effective. As Morgagni hernia can be accompanied with many congenital cardiac anomalies, cardiac surgeons should be familiar with the trans-sternal approach to the defect.

Immunotherapy of inflammatory bowel disease (IBD) through mesenchymal stem cells.

Many pathophysiologic pathways and immune-pathologic etiologies are addressed as Inflammatory bowel disease (IBD) causes. Moreover, dysfunction of the immune system leads to inflammatory responses against intestinal components that boost disease severity. The use of routine treatments has limitations. Besides, patients may experience drug resistance. Therefore, the use of novel and effective therapies is essential. Relying on the immune regulatory functions of Mesenchymal Stem Cells (MSCs), researchers have suggested possible benefits of MSCs administration for IBD, both in experimental and clinical studies. Experimental animal models of IBD have shown effects of MSCs, MSC-derived exosomal micro RNAs, and MSC-based drug delivery systems on the regulation of the immune system (Th17 suppression versus T-regular cell biased responses). These studies have suggested MSCs' benefits on intestinal integrity, improved smooth cell function, and tissue repair. On the other hand, various clinical trials have been registered for MSCs application in IBD patients that show reliable safety in humans. Most clinical trials have used MSCs of bone marrow, umbilical cord, and adipose tissue that have been administered by intravenous or intra-tissue injection. Studies have evaluated clinical outcomes, patient symptoms, or healing processes; while immunological studies in the clinical era are missing. As we reviewed, huge shreds of experimental shreds of evidence have led to the inception of multiple clinical trials in phase I/II, showing promising results for IBD treatment. We suggest that further clinical investigation should be more focused on in-vitro/in-vivo assessed outcomes as well as the immunological endpoints to have more reliable results with more support for laboratory evidence.

A Rare Case of Dandy-Walker Syndrome.

Dandy-Walker syndrome (DWS) is a rare congenital malformation characterized by hypoplasia of the cerebellar vermis and its upward rotation and cystic enlargement of the fourth ventricle. The clinical manifestations include psychomotor retardation, ataxia and hydrocephalus. We report a case of 16-year-old female patient in Ali Abad Teaching Hospital who was suffering from unsteady gait, memory deterioration and urinary incontinence. A brain magnetic resonance imaging revealed enlarged cystic posterior fossa, dilated fourth ventricles and upward rotated cerebellar vermis which were indicating DWS. The patient prepared for planned surgical operation and a written informed consent was obtained from her parents for surgery and general anesthesia. A cystoperitoneal (CP) shunt was placed and then the patient transferred to recovery room. After recovery and hospital stay, the patient discharged with improved clinical symptoms.

Identification and analysis of iron transporters from the fission yeast Schizosaccharomyces pombe.

Iron is an essential trace metal ion required for all living organisms, and is taken up by iron transporters. Here, we identified and characterized three-candidate high-affinity (Fio1, Frp1 and Frp2) and two-candidate low-affinity iron transporters (Fet4 and Pdt1) from the fission yeast Schizosaccharomyces pombe. Protein sequence analyses revealed that Fio1 is a multicopper oxidase that contains three cupredoxin domains with eleven candidate iron-binding ligands, whereas Frp1 harbors a ferric reductase domain with three-candidate heme-binding ligands. Protein sequence analyses also revealed that Fet4 and Pdt1 are integral membrane proteins with 10 and 11 transmembrane regions, respectively. Deletion of fio1 and, to a lesser extent, frp1 impaired growth under iron-depleted conditions, whereas deletion of frp1 and, to a lesser extent, frp2 inhibited growth under iron-replete conditions. Deletion of fet4 and pdt1 did not affect the growth of cells under iron-depleted and iron-replete conditions. Deletion of fio1 or frp1 also increased the sensitivity of cells to other transition metals. The copper sensitivity of Δfio1 cells could be rescued by iron, suggesting that the addition of iron might decrease the uptake of potentially toxic copper in Δfio1 cells. The copper sensitivity of Δfio1 cells could also be rescued by deletion of frp1, suggesting that Fio1 and Frp1 may function together in iron and copper uptakes in S. pombe. Our results revealed that iron and copper uptake systems may be partially overlapped in S. pombe.

Methodology for Lost Gas Determination from Exploratory Coal Cores and Comparative Evaluation of the Accuracy of the Direct Method.

In the coal exploration of China, the commonly used direct method within 120 min has potential errors in lost gas calculation of deep coal seam for its complex geological conditions. The exploration of deep coal resources by drilling holes in Huainan of Eastern China offered an opportunity to starting research into developing a new method. A developed method with error analysis was constructed to estimate the lost gas using the total desorption process obtained from exploratory coal cores. The accuracy of the direct method was also evaluated comparatively. The result shows that the desorption curve of tested coal samples matches the fitted curve equation. Desorption temperature and the tectonic coal with associated pore characteristics significantly affect the variation of the adsorption characteristics and the estimation of lost gas. The direct method obviously underestimates the lost gas, and methodology using a new lost gas estimation procedure with additional residual gas allows for achieving relatively accurate results of the determination of gas content in coal seams. The calculated result of the new method is about 1.00-1.41 times that of the direct method. The error analysis of desorption results allowed us to determine the dependence between the time (retrieval time and desorption time) and determination method. The time used for desorption in the tank is allowed to extend to less than 400 min or more than 1000 min, which is very potentially important to accurately get the coalbed gas content for coring samples, especially deep exploratory cores for field application.

Synthesis of New Naphthyl Aceto Hydrazone-Based Metal Complexes: Micellar Interactions, DNA Binding, Antimicrobial, and Cancer Inhibition Studies.

In the present study, naphthyl acetohydrazide (HL) ligand was prepared and used for the synthesis of new six amorphous transition metal (Co(II), Ni(II), Cu(II), Zn(II), Pb(II), Cd(II)) complexes. All the compounds were characterized by elemental analysis, UV-vis, FT-IR, 1H- and 13C-NMR, and Matrix-Assisted Laser Desorption Ionization (MALDI). The solubilization study was carried out by estimating the interaction between the metal complexes with surfactants viz. sodium stearate (SS) and Cetyltrimethylammonium bromide (CTAB). UV-Visible spectroscopy was employed to determine partitioning and binding parameters, whereas electrical conductivity measurements were employed to estimate critical micellar concentration (CMC), the extent of dissociation, and free energy of micellization. The CT-DNA interaction of synthesized compounds with DNA represents the major groove binding. The synthesized ligand and metal complexes were also tested against bacterial and fungal strains and it has been observed that Cu(II) complex is active against all the strains except Candida albicans, while Cd(II) complex is active against all bacterial and fungal strains except Pseudomonas. Among all compounds, only the Pd(II) complex shows reasonable activity against cervical cancer HeLa cell lines, representing 97% inhibition.

Screening of small molecule libraries using combined text mining, ligand- and target-driven based approaches for identification of novel granzyme H inhibitors.

Granzymes are serine proteases synthesized by CTL and NK cells. Five granzyme genes (GzmA, -B, -H, -K, -M) are present in humans, which are located at three different chromosomal loci. Being serine proteases, the binding pocket constitutes a catalytic triad (i.e., His59, Asp103 and Ser197). Granzymes are released into target (cancerous and virally infected) cells by a specialized process known as granule exocytosis pathway. After internalization, these proteases initiate apoptosis. Granzymes are also involved in other non-apoptotic immune associated roles like ECM remodeling, cytokine modulation, killing of pathogens through generation of phagosomes. Their intracellular activity is regulated by specialized inhibitors knows as SERPINs. However, if these proteases are secreted in excess into the extracellular environment, their regulation becomes important as otherwise they start self-damage to the tissues thereby worsening the disease conditions. Efforts are being made to identify potential inhibitors for regulation of these proteases in an extracellular environment. Physiological and synthetic inhibitors have been reported against some members however there is no known inhibitor against extracellular human GzmH. Thus, in the current study, we investigated small molecule databases for the identification of potential molecules having the ability to inhibit GzmH by combined molecular simulations, which can ultimately be used as a potential therapeutic agent.

Diagnostic Value of Cholinesterase Activity for the Development of Postoperative Delirium after Cardiac Surgery.

BACKGROUND: Depression of cholinesterase (CHE) activity has been reported to lead to an amplified neuroinflammatory response, which clinically manifests as postoperative delirium (PD). This observational study investigates the association between CHE activity and the development of PD following elective cardiac surgery. METHODS: Patients with preexisting neurologic deficits or carotid artery disease as well as patients undergoing reoperations or procedures under circulatory arrest have been excluded from this study. The Mini-Mental State Examination, the Confusion Assessment Method for the Intensive Care Unit, and the Intensive Care Delirium Screening Checklist were performed at regular intervals. CHE activity was estimated pre- and postoperatively until postoperative day (POD) 5 and at discharge. RESULTS: A total of 107 patients were included. PD was diagnosed in 34 (31.8%) patients, who have been compared with those without PD. Time on ventilator, length of ICU, and hospital stay were longer in patients with PD (p = 0.001, p < 0.001, and p = 0.004, respectively). MMSE scores were lower in patients with PD (p < 0.001; p = 0.015). CHE activity on POD 1 to 4 as well as at discharge were lower in the delirium group (p = 0.041; p = 0.029; p = 0.015; p = 0.035; p = 0.028, respectively). A perioperative drop of CHE activity of more than 50% and a postoperative CHE activity below 4,800 U/L (on POD 0) were independently associated with an increased risk of development of PD (p = 0.038; p = 0.008, respectively). CONCLUSION: In addition to the established functional tests, routine estimation of CHE activity may serve as an additional diagnostic tool allowing for the timely diagnosis and treatment of PD in cardiac surgery patients.

Latissimus Dorsi Flap in the Treatment of Thoracic Wall Defects After Medial Sternotomy.

Background: This study aimed to describe the subjective and objective results of the latissimus dorsi muscle flap and propose it as a reconstructive option for postoperative thoracic defects. Methods: A systematic search for cases with pedicle-based latissimus dorsi flaps performed after medial sternotomy was conducted, and all cases occurred between 2010 and August 2017. Preoperative, intraoperative, and postoperative factors were retrospectively analyzed and then the correlations between prognostic factors and outcomes of flap surgery were calculated. Furthermore, an evaluation of the subjective quality of life after flap surgery was performed using questionnaires. Results: A total of 25 cases were identified (8 female and 17 male patients) with the mean age of 75.28 years (range, 55-88 years). The average survival rate was 39.63 ± 23.03 months. The proportion of patients with a survival rate of 1 year was 84.00% (21 patients), and the proportion of patients with a 2-year survival rate was 80.00% (20 patients). While 24% of all patients who had latissimus dorsi flap operations experienced no complications, 64% of them developed minor complications (non-life-threatening, Clavien-Dindo grades I-IIIb) and 12% of them developed major complications (life-threatening, Clavien-Dindo grades IV-V). There was a significant correlation between the low survival rate and risk factors such as a positive history of smoking (P = .034), renal insufficiency (P = .022), metabolic syndrome (P = .004), and the presence of postoperative complications (P < .00002). No significant correlation was observed between the survival rate and obesity (P = .396), hyperlipoproteinemia (P = .684), arterial hypertonia (P = .0450), diabetes (P = .891), cardiovascular comorbidities (P = .794), the interval between sternotomy and latissimus flap surgery (P = .075), the duration of flap surgery (P = .207), sternal osteitis (P = .78), and intraoperative application of norepinephrine (P = .818). We identified metabolic syndrome (hazard ratio: 6.27), renal insufficiency (hazard ratio: 3.935), and the presence of postoperative complications (hazard ratio: 2.965) as high-risk prognostic factors. The subjective evaluations revealed positive reports from the patients with an average score of 1.86 ± 1.03 (1.0 = very good; 5.0 = poor). Conclusions: The majority of the patients with defects after median sternotomy were treated successfully with the latissimus dorsi flap. High survival rates, low rates of severe complications, and subjective scoring of improved life quality make this procedure relative safe and reliable. However, some prognostic risk factors limit the outcome, so these factors should be considered during surgical planning.

Safety and efficacy of digital chest drainage units compared to conventional chest drainage units in cardiac surgery.

OBJECTIVES: The use of digital chest drainage units (CDUs) has become increasingly common in thoracic surgery due to several advantages. However, in cardiac surgery, its use is still limited in favour of conventional analogue CDUs. In order to investigate the potential benefit of digital CDUs in cardiac surgery, we compared the safety and efficacy of both systems in patients undergoing cardiac surgery at our centre. METHODS: We retrospectively investigated 265 consecutive patients who underwent cardiac surgery at our institution between June 2017 and October 2017. These patients were divided into 2 groups: patients with analogue (A, n = 65) and digital CDUs (D, n = 200). Postoperative outcome was analysed and compared between both groups. In addition, the 'user experience' was evaluated by means of a questionnaire. RESULTS: The median age of the cohort was 70 years (P = 0.167), 25.3% of patients were female (P = 0.414). There were no differences in terms of re-explorative surgery or use of blood products. Nor was there a difference in the overall amount of fluid collected. However, during the first 6 h, more fluid was collected by the digital CDUs. The overall rate of technical failure was 0.4%. We observed a significantly higher rate of clotting in the tubing system of the digital CDUs (P = 0.042). Concerning the user experience, the digital CDUs were associated with a more favourable ease of use on the regular wards (P < 0.001). With regard to the overall user experience, the digital CDUs outperformed the analogue systems (P = 0.002). CONCLUSIONS: Digital CDUs can be safely and effectively applied in patients after cardiac surgery. Due to the improved patient mobility and simplified chest tube management, the use of digital CDUs may be advantageous for patients after cardiac surgery. However, the issue of clotting of the tubing systems should be addressed by further technical improvements.

Complex Valve Surgery in Elderly Patients: Increasingly Necessary and Surprisingly Feasible.

OBJECTIVES: The increasing proportion of elderly patients in cardiac surgery poses additional challenges for the clinical management and leads to a higher operative risk due to multiple comorbidities of these patients. We reviewed the outcome of patients who were 75 years and older and underwent complex multiple valve surgery at our institution. METHODS: A retrospective review was performed to identify patients who were 75 years and older and underwent multiple valve surgery between January 2011 and May 2016 at our institution. Patients were assigned to one out of four subgroups: combined aortic and mitral valve surgery (group AM), aortic and tricuspid valve surgery (group AT), mitral and tricuspid valve surgery (group MT), and aortic, mitral, and tricuspid valve surgery (group AMT). RESULTS: A total of 311 patients underwent multiple valve surgery, of whom 119 (38.3%) were 75 years and older (median: 78 [25th-75th quartile: 76-80]). The estimated operative mortality (EuroSCORE II) in the overall cohort was 10.7%. The observed 30-day mortality was 4.2% (7% in group AM, 0% in group AT, 2.2% in group MT, 3.8% in group AMT; p = 0.685). Main complications were reexplorative surgery in 16%, adverse cerebrovascular events in 6.7%, prolonged mechanical ventilation in 10.1%, renal replacement therapy in 15.1%, nosocomial pneumonia in 15.1%, and pacemaker implantation in 18.5%. CONCLUSIONS: This study demonstrates the feasibility of complex multiple valve surgery in elderly patients. The observed perioperative mortality was lower than predicted. However, we observed a substantial rate of adverse events; therefore, careful patient selection is required in this high-risk patient population.

Turning Things Around: The Role of Prone Positioning in the Management of Acute Respiratory Failure After Cardiac Surgery.

OBJECTIVES: The aim of this study was to determine the benefit of prone positioning (PP) in patients developing acute respiratory failure (ARF) after cardiac surgery. DESIGN: A retrospective analysis. SETTING: Review of the institutional database between October 2016 and October 2018 revealed 24 patients who underwent PP for the treatment of ARF after cardiac surgery. PARTICIPANTS: The authors found 24 patients who underwent PP for the treatment of ARF after cardiac surgery. This included 10 patients who required extracorporeal membrane oxygenation (ECMO) therapy. Among them, 6 patients with simultaneous PP and ECMO therapy. INTERVENTIONS: Data were collected at the time of PP, 6 hours after PP, at the end of PP, and 6 hours after return to supine position (SP). MEASUREMENTS AND MAIN RESULTS: The median duration of postoperative mechanical ventilation was 281 hours (183-528 hours). Prone positioning was carried out on the fourth postoperative day (POD), with a total of 5 patients undergoing PP within 24 hours following surgery. The median duration of PP before return to SP was 12 hours (12-16 hours), with the maximal duration of PP being 22 hours in this cohort. The authors observed an increase in Horowitz index (HI) at the end of PP (p < 0.001) as well as 6 hours after supine positioning. In the subgroup of patients who underwent PP on ECMO (v-a ECLS = 3, v-v ECMO = 3), a significant reduction of ECMO support was achieved from 3.0 (2.2-5.6) liters/min to 2.5 (2.0-4.6) liters/min (p = 0.023). No adverse events occurred during the positioning of the patients. CONCLUSIONS: Prone positioning can be considered for the treatment of ARF after cardiac surgery to improve short-term respiratory conditions and possibly facilitate ECMO weaning.

Design and training effects of a physical reality simulator for minimally invasive mitral valve surgery.

OBJECTIVES: Minimally invasive mitral valve surgery (MIMVS) through an endoscopic right minithoracotomy is a well-established yet complex procedure that has a challenging learning curve. We have developed a simulator for MIMVS and evaluated its short- and long-term training effects. METHODS: Trainees without simulator experience or training in MIMVS were divided into 2 groups (10 students and 10 residents) and participated in a 5-day training course after initial instruction. Each trainee performed a ring annuloplasty. Scores were given by a supervisor who assessed 5 skills. The duration of each procedure was also measured. To evaluate the long-term effect of the training course, trainees performed the same procedure 4 weeks after the last session. RESULTS: Trainees in the resident group were significantly older compared to those in the student group and had a mean surgical experience of 4.4 ± 0.78 years standard error of the mean. All other demographic data were similar. Significant learning curves could be achieved in both groups over the course of 5 days with regard to total skill scores and total duration. However, when we compared the learning curves of both groups, no significant difference could be seen. Long-term performance in both groups was still significantly better compared to that in the first training session. CONCLUSIONS: Training with our simulator provided a significant enhancement of a trainee's performance. This learning effect was achieved in both groups and was still evident 4 weeks later. We strongly recommend our simulator for simulation-based surgical education of cardiac surgeons interested in MIMVS.

Is there a correlation between late re-exploration after cardiac surgery and removal of epicardial pacemaker wires?

BACKGROUND: Re-exploration for bleeding accounts for increased morbidity and mortality after major cardiac operations. The use of temporary epicardial pacemaker wires is a common procedure at many departments. The removal of these wires postoperatively can potentially lead to a serious bleeding necessitating intervention. METHODS: From Jan 2011 till Dec 2015 a total of 4244 major cardiac procedures were carried out at our department. We used temporary epicardial pacemaker wires in all cases. We collected all re-explorations for bleeding and pericardial tamponade from our surgical database and then we focused on the late re-explorations, meaning on the 4th postoperative day and thereafter, trying to identify the removal of the temporary pacemaker wires as the definite cause of bleeding. Patients' records and medication were examined. RESULTS: Thirty-nine late re-explorations for bleeding, consisting of repeat sternotomies, thoracotomies and subxiphoid pericardial drainages, were gathered. Eight patients had an acute bleeding incidence after removal of the temporary wires (0.18%). In four of these patients, a pericardial drainage was inserted, whereas the remaining patients were re-explorated through a repeat sternotomy. Two patients died of the acute pericardial tamponade, three had a blood transfusion and one had a wound infection. Seven out of eight patients were either on dual antiplatelet therapy or on combination of aspirin and vitamin K antagonist. CONCLUSIONS: A need for re-exploration due to removal of the temporary pacemaker wires is a very rare complication, which however increases morbidity and mortality. Adjustment of the postoperative anticoagulation therapy at the time of removal of the wires could further minimize or even prevent this serious complication.

Long term biventricular support with Berlin Heart Excor in a Septuagenarian with giant-cell myocarditis.

Giant-cell myocarditis (GCM) is known as a rare, rapidly progressive, and frequently fatal myocardial disease in young and middle-aged adults. We report about a 76 year old male patient who underwent implantation with a biventricular Berlin Heart Excor system at the age of 74 due to acute biventricular heart failure caused by giant-cell myocarditis. The implantation was without any surgical problems; however, a difficulty was the immunosuppressive therapy after implantation. Meanwhile the patient is 76 years old and lives with circulatory support for about 3 years without major adverse events. Also, in terms of mobility in old age there are no major limitations. It seems that in even selected elderly patients an implantation of a long term support with the biventricular Berlin Heart Excor is a useful therapeutic option with an acceptable outcome.