Evaluation of two doses (20 mL and 15 mL) of 0.25% bupivacaine in pericapsular nerve group block for patient positioning for sub-arachnoid block during hip fracture surgery: A single-centre, randomised comparative trial.

Background and Aims: Peri-capsular nerve group (PENG) block is a novel ultrasound (US)-guided technique to achieve regional analgesia in hip fractures. We compared the effectiveness of two doses of 0.25% bupivacaine (20 mL and 15 mL) in the US-guided PENG block for positioning patients for sub-arachnoid block (SAB) during hip fracture surgery. Methods: The randomised trial included 60 patients aged 40-90 years undergoing hip fracture surgery under SAB. PENG block was given by a US-guided approach with the patient in a supine position 20 minutes before SAB, and a total of 20 mL and 15 mL of bupivacaine (0.25%) were given in groups A and B, respectively. The primary outcome was to measure and compare the ease of positioning (EOP) of patients for the conduct of SAB. The secondary outcome was the pain assessment at rest and 15° leg raise position at baseline and 10 and 20 minutes post block using the verbal analogue scale (VAS). Continuous variables were compared using the t-test, and categorical variables were analysed using Pearson's Chi-square test or Fisher's exact test. Results: The mean (standard deviation) grade of EOP for SAB was significantly better in group A (2.47 (0.73) (95% confidence interval [CI]: 2.19-2.69)) than in group B (1.86 (0.62) (95% CI: 1.65-2.1)) (P = 0.001). The decrease in VAS scores was significantly higher in group A compared to group B at resting and 15° leg raise position at all-time points (P < 0.05). Conclusion: A dose of 20 mL of 0.25% bupivacaine shows better outcomes than 15 mL regarding the patient's positioning during the SAB.

Differences in Leukocyte Transcriptomes of Morbidly Obese Patients With High Output Heart Failure: A Pilot Study.

Background and Objectives: Heart failure is characterized by alterations of gene expression that provide insight into the underlying pathophysiologic mechanisms. However, obesity-related high output heart failure (HOHF) is a specific phenotype of heart failure that has not been studied using gene expression. Our aim in this study was to examine the variances in leukocyte transcriptomes of morbidly obese patients with HOHF. Methods: In this cross-sectional study, we applied stranded total RNA-sequencing to six patients with morbid obesity and HOHF and 6 patients with morbid obesity and non-HOHF. Differential gene expression was calculated, and Ingenuity Pathway Analysis software was used to interpret the canonical pathways, functional changes, upstream regulators, and networks in these patients. Results: We found in patients with HOHF that there were 116 differentially expressed genes with upregulation of 114 genes and downregulation of 2 genes. The differentially expressed genes were involved with cell proliferation, mitochondrial function, erythropoiesis, erythrocyte stability, and apoptosis. The top upregulated canonical pathways associated with differentially expressed genes were autophagy, adenosine monophosphate-activated protein kinase signaling, and senescence pathways. We identified GATA binding protein 1 as an upstream regulator and nuclear factor kappa-light-chain-enhancer of activated B cells associated network. Conclusions: We are the first to report the differential gene expression in patients with obesity-related HOHF and reveal the various pathophysiologic mechanisms underlying the disease. Further research is needed to determine the role of cellular function and maintenance, inflammation, and iron homeostasis in obesity-related HOHF.

Impact of Biopsy Proven Liver Fibrosis on Patients Undergoing Evaluation and Treatment for Advanced Heart Failure Surgical Therapies.

There is a paucity of data regarding the impact of liver fibrosis on patients with stage D heart failure (HF). We conducted a retrospective study (January 1, 2017 to December 12, 2020) in patients with stage D HF who underwent liver biopsy as part of their advanced HF therapy evaluation. Baseline characteristics and 1-year outcomes were compared between no- or mild-to-moderate-fibrosis (grade 0 to 2) and advanced-fibrosis (grade 3 to 4) groups. Of 519 patients with stage D HF, 136 who underwent liver biopsy (113 [83%] no or mild-to-moderate fibrosis and 23 [17%] advanced fibrosis) were included. A total of 71 patients (52%) received advanced HF therapies (23 heart transplantation, 48 left ventricular assist devices). One-year mortality was higher among patients with advanced fibrosis (52% vs 18%, p <0.001). Further subgroup analysis suggested a trend toward increased 1-year mortality among patients with advanced fibrosis who underwent advanced therapies (37% vs 13%, p = 0.09). There was a trend of lower likelihood of receiving advanced HF therapies in the advanced-fibrosis group, only 1 heart transplantation and 7 left ventricular assist devices, but it did not reach statistical significance (35% vs 56%, p = 0.06). After adjustment for confounders, degree of liver fibrosis was an independent predictor of mortality (odds ratio 6.2; 95% 1.27 to 30.29, p = 0.02). We conclude that advanced liver fibrosis is common among patients with stage D HF who undergo evaluation for advanced HF surgical therapies and significantly increases 1-year mortality. Further larger studies are needed to support our findings.

Comparative evaluation of three techniques for paramedian subarachnoid block: Point-of-care preprocedural ultrasound assisted, real-time ultrasound guided and landmark based.

Background and Aims: Preprocedural ultrasound (US) assisted and real-time US-guided subarachnoid block (SAB) are useful adjuncts for successful SAB. This study compared the feasibility and efficacy of real-time US-guided SAB with preprocedural US-assisted and landmark-based SAB using paramedian approach. Methods: The study enroled 150 American Society of Anesthesiologists I and II patients, aged 20-65 years, scheduled for lower limb orthopaedic surgery under SAB. In group L (n = 50), the patients underwent landmark-guided SAB utilising paramedian approach. In group P (n = 50), preprocedural US-assisted SAB was instituted and in group M (n = 50) real-time US-guided SAB was administered. The number of needle attempts for a successful SAB was the primary outcome. The secondary outcomes included successful SAB in first attempt, time taken to perform SAB and patients' satisfaction. Results: The number of attempts for SAB were (mean ± standard deviation = 1.05 ± 0.35, 1.00 ± 0.28, 1.03 ± 0.26) in groups L, P and M, respectively (P = 0.436). The SAB was successful in the first attempt in 82%, 82% and 80% in groups L, P and M, respectively (P = 0.207). The time taken for the successful SAB was more in group M as compared to groups L and P (groups L and M, P = 0.045 and groups P and M, P = 0.004). The patients' satisfaction score was comparable. Conclusion: Real-time US guidance for spinal anaesthesia resulted in needle attempts comparable to landmark and preprocedural US-assisted SAB in patients with a normal spine. The time required for the completion of the block was more in real-time US-guided SAB.

Potential use of ubiquinol and d-ribose in patients with heart failure with preserved ejection fraction.

•Manuscript Highlights.•HFpEF is associated with reduced ATP production in the myocardium.•Ubiquinol and d-ribose both contribute to the generation of myocardial ATP.•Both ubiquinol and d-ribose are being studied as supplemental treatments for patients with HFpEF.

Hazardous alcohol use among patients with schizophrenia and depression.

AIMS: The current study aimed to 1) report the prevalence of hazardous alcohol use in an outpatient population among those with schizophrenia and depressive disorders, 2) assess the sociodemographic and clinical correlates of hazardous alcohol use, 3) examine the association of hazardous alcohol use with severity of depression, anxiety and smoking, and 4) assess the association of hazardous alcohol use with quality of life. METHODS: Three hundred ten outpatients seeking treatment at a tertiary psychiatric institute with a diagnosis of either schizophrenia spectrum disorder or depressive disorder were included in the study. Patients were assessed for hazardous alcohol use using the Alcohol Use Disorders Identification Test. Information on sociodemographic correlates, clinical history, severity of symptoms of depression and anxiety, as well as quality of life (QOL) was collected. RESULTS: The overall prevalence of hazardous alcohol use among the sample was 12.6%. The prevalence of hazardous alcohol use among patients with depression and schizophrenia was 18.8% and 6.4%, respectively. Compared to those who were students, patients who were gainfully employed or unemployed were more likely to engage in hazardous alcohol use (Odds Ratio (OR) = 5.5 and 7.7, respectively). Patients with depression compared to those with schizophrenia (OR = 11.1) and those who were current smokers compared to those who had never smoked (OR = 14.5) were more likely to engage in hazardous alcohol use. Hazardous alcohol use was associated with lower QOL in the physical health domain (p = 0.002). CONCLUSION: Given the significant prevalence of hazardous alcohol use in this population, routine screening for hazardous alcohol use and brief interventions could be an effective way of managing this comorbidity. There is a need to develop and evaluate culturally appropriate brief interventions based on patient preference in this setting.

Thrombosis in the Surgically Corrected Anomalous Right Coronary Artery after Reimplantation in Aorta.

A 32-year-old African American female presented with dyspnea, and after several cardiac diagnostic tests, the diagnosis of an anomalous origin of the RCA from the pulmonary trunk was established by multislice coronary CT angiography. She underwent surgical correction with reimplantation of the RCA, from the pulmonary artery to the aortic root. However, 10 days after surgery, she developed frequent episodes of chest pain, and repeat coronary CTA showed a partially occlusive thrombus in the surgically reimplanted RCA. Anticoagulation with warfarin resulted in complete resolution of the patient's symptoms.

Incidence and 1-Year Outcomes of Perioperative Atrial Arrhythmia in Elderly Adults After Hip Fracture Surgery.

OBJECTIVES: To determine the incidence and 1-year outcomes of an elderly population with perioperative atrial arrhythmia (PAA) within 7 days of hip fracture surgery. DESIGN: Retrospective cohort study. SETTING: The Rochester Epidemiology Project (REP). PARTICIPANTS: Elderly adults consecutive undergoing hip fracture repair from 1988 to 2002 in Olmsted County, Minnesota (N = 1,088, mean age 84.0 ± 7.4, 80.2% female). MEASUREMENTS: Baseline clinical variables were analyzed in relation to survival using Cox proportional hazards methods for comparison. RESULTS: Sixty-one participants (5.6%) developed PAA within the first 7 days. During 1 year of follow-up, 239 (22%) participants died. PAA was associated with greater mortality (45% vs 21%; hazard ratio (HR) = 2.8, 95% confidence interval (CI) = 1.9-4.2). Other mortality risk factors were male sex (HR = 2.0, 95% CI = 1.5-2.6), congestive heart failure (HR = 2.1, 95% CI = 1.7-2.8), chronic renal insufficiency (HR = 2.0, 95% CI = 1.5-2.8), dementia (HR = 2.9, 95% CI = 2.2-3.7), and American Society of Anesthesiologists risk Class III, IV, or V (HR = 3.3, 95% CI = 1.9-5.9). CONCLUSION: Elderly adults undergoing hip fracture surgery who develop PAA within 7 days have significantly higher 1-year mortality than those who do not. Further studies are indicated to determine whether prevention of PAA will reduce mortality in this population.

Clinical presentation and outcome of perioperative myocardial infarction in the very elderly following hip fracture surgery.

BACKGROUND: Patterns of clinical symptoms and outcomes of perioperative myocardial infarction (PMI) in elderly patients after hip fracture repair surgery are not well defined. METHODS: A retrospective 1:2 case-control study in a cohort of 1212 elderly patients undergoing hip fracture surgery from 1988 to 2002 in Olmsted County, Minnesota. RESULTS: The mean age was 85.3 ± 7.4 years; 76% female. PMI occurred in 167 (13.8%) patients within 7 days, of which 153 (92%) occurred in first 48 hours; 75% of patients were asymptomatic. Among patients with PMI, in-hospital mortality was 14.4%, 30-day mortality was 29 (17.4%), and 1-year mortality was 66 (39.5%). PMI was associated with a higher inpatient mortality rate (odds ratio [OR], 15.1; confidence interval [CI], 4.6-48.8), 30-day mortality (hazard ratio [HR], 4.3; CI, 2.1-8.9), and 1-year mortality (HR, 1.9; CI, 1.4-2.7). CONCLUSION: Elderly patients, after hip fracture surgery, have a higher incidence of PMI and mortality than what guidelines indicate. The majority of elderly patients with PMI did not experience ischemic symptoms and required cardiac biomarkers for diagnosis. The results of our study support the measurement of troponin in postoperative elderly patients for the diagnosis of PMI, in order to implement in-hospital preventive strategies to reduce PMI-associated mortality.