Predictors of outcomes of patients ≥ 80 years old admitted to intensive care units in Poland - a post-hoc analysis of the VIP2 prospective observational study.

INTRODUCTION: Elderly patients pose a significant challenge to intensive care unit (ICU) clinicians. In this study we attempted to characterise the population of patients over 80 years old admitted to ICUs in Poland and identify associations between clinical features and short-term outcomes. MATERIAL AND METHODS: The study is a post-hoc analysis of the Polish cohort of the VIP2 European prospective observational study enrolling patients > 80 years old admitted to ICUs over a 6-month period. Data including clinical features, clinical frailty scale (CFS), geriatric scales, interventions within the ICU, and outcomes (30-day and ICU mortality and length of stay) were gathered. Univariate analyses comparing frail (CFS > 4) to non-frail patients and survivors to non-survivors were performed. Multivariable models with CFS, activities of daily living score (ADL), and the cognitive decline questionnaire IQCODE as predictors and ICU or 30-day mortality as outcomes were formed. RESULTS: A total of 371 patients from 27 ICUs were enrolled. Frail patients had significantly higher ICU (58% vs. 44.45%, P = 0.03) and 30-day (65.61% vs. 54.14%, P = 0.01) mortality compared to non-frail counterparts. The survivors had significantly lower SOFA score, CFS, ADL, and IQCODE than non-survivors. In multivariable analysis CFS (OR 1.15, 95% CI: 1.00-1.34) and SOFA score (OR 1.29, 95% CI: 1.19-1.41) were identified as significant predictors for ICU mortality; however, CFS was not a predictor for 30-day mortality ( P = 0.07). No statistical significance was found for ADL, IQCODE, polypharmacy, or comorbidities. CONCLUSIONS: We found a positive correlation between CFS and ICU mortality, which might point to the value of assessing the score for every patient admitted to the ICU. The older Polish ICU patients were characterised by higher mortality compared to the other European countries.

Preoperative Oral Carbohydrate (CHO) Supplementation Is Beneficial for Clinical and Biochemical Outcomes in Patients Undergoing Elective Cesarean Delivery under Spinal Anaesthesia-A Randomized Controlled Trial.

BACKGROUND: Preoperative fasting and surgery cause metabolic stress, insulin resistance with ketosis, and postoperative nausea and vomiting (PONV). Oral carbohydrate loading strategy (CHO) improves outcomes in labor and general surgery. We aimed to compare the effectiveness of CHO with standard fasting in patients undergoing elective cesarean delivery (CD) under spinal anesthesia. METHODS: A single-center, parallel, prospective randomized controlled trial (RCT) was conducted in a tertiary university obstetrics department at Pomeranian Medical University in Szczecin, Poland. Patients were randomly assigned (1:1 ratio) to the CHO group (oral carbohydrate 2 h before elective CD, n = 75) or the SF group (control-standard fasting, n = 73). The main outcome measures were incidence and severity of PONV at 6 and 24 h after CD, time to the first peristalsis, time to first bowel movement, and biochemical parameters indicating ketosis in mothers and their children. RESULTS: A total of 148 adult females with singleton pregnancies undergoing elective CD under spinal anesthesia (ASA I and II) were included in the final analysis. At 24 h after CD, 8.0% from the CHO group vs. 20.55% reported three or more episodes of vomiting or dry retching as compared to patients in the SF group (p = 0.041). Preoperative CHO supplementation decreased preoperative feelings of hunger (p < 0.001) and thirst (p < 0.001). Laboratory results in the CHO group showed higher plasma pH (p = 0.001) and glucose (p < 0.001), lower F2-isoprostane in plasma (p = 0.049) and urine (p = 0.018), lower urine F2-isoprostane/creatinine ratio (p = 0.045) than in the SF group. HOMA-IR (p < 0.001) and lactate (p < 0.001) were higher in the CHO group than in the control group. CONCLUSIONS: There was no significant difference in the incidence or severity of early PONV at 6 h. The incidence of vomiting or dry retching at 24 h after cesarean delivery was lower in the CHO group as compared to standard starvation, but the combined results of PONV frequency and severity on the Wengritzky scale did not differ between the two study groups. Preoperative CHO supplementation decreased preoperative feelings of hunger and thirst, enhancing the comfort of pregnant women. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04069806.

The Association of Infection with Delirium in the Post-Operative Period after Elective CABG Surgery.

Delirium is one of the most common complications of coronary artery by-pass graft (CABG) surgery. The identification of patients at increased risk of delirium and the implementation of preventive measures to reduce the risk of postoperative delirium is necessary to improve treatment outcomes after CABG. The aim of this study was to assess the association between postoperative delirium and postoperative infection and 10-year mortality in patients undergoing CABG surgery. This is a retrospective, observational cohort study of patients undergoing planned on-pump CABG between April 2010 and December 2012. We analysed a group of 3098 patients operated on in our cardiac surgery centre, from whom we selected a cohort of patients undergoing planned CABG surgery. All patients were assessed for postoperative infection, such as pneumonia, bloodstream infections (BSIs) and surgical site infections (SSIs). Patients who experienced postoperative delirium were significantly more likely to have infection (7.4% vs. 22%; p = 0.0037). As regards particular types of infection, significant differences were only found for pneumonia and sternal SSIs. Patients who experienced postoperative delirium had significantly lower 5-year (p = 0.0136) and 10-year (p = 0.0134) survival. Postoperative delirium significantly increases long-term mortality in patients undergoing CABG surgery. Pneumonia and sternal SSIs significantly increase the risk of postoperative delirium in cardiac surgery patients.

Impact of Post-Operative Infection after CABG on Long-Term Survival.

Coronary artery bypass grafting (CABG) is one of the most common cardiac surgical procedures. It is commonly known that post-operative infection has a negative impact on the patient's short-term treatment outcomes and long-term prognosis. The aim of the present study was to assess the impact of perioperative infection on 5-year and 10-year survival in patients undergoing elective on-pump CABG surgery. The present prospective observational study was carried out between 1 July 2010 and 31 August 2012 among patients undergoing cardiac surgery at our centre. Infections were identified according to the ECDC definitions. We initially assessed the incidence of infection and its relationship with the parameters analysed. We then analysed the effect of particular parameters, including infection, on 5-year and 10-year survival after surgery. We also analysed the impact of particular types of infection on the risk of death within the period analysed. The significant risk factors for reduced survival were age (HR 1.05, CI 1.02-1.07), peripheral artery disease (HR 1.99, CI 1.28-3.10), reduced LVEF after surgery (HR 0.96, CI 0.94-0.99), post-operative myocardial infarction (HR 1.45, CI 1.05-2.02) and infection (HR 3.10, CI 2.20-4.28). We found a strong relationship between post-operative infections and 5-year and 10-year mortality in patients undergoing CABG. Pneumonia and BSI were the only types of infection that were found to have a significant impact on increased long-term mortality after CABG surgery.

Histamine and Serotonin Levels in Bone Marrow Stem Cells Niche as Potential Biomarkers of Systemic Mastocytosis and Myeloproliferative Disorders.

Bone marrow studies currently provide a lot of valuable information in the diagnostics of hematological diseases including hematopoietic stem cells disorders. Our studies on low-molecular weight organic compounds in bone marrow stem cell niche in various pathogenic conditions, revealed relatively high variability of histamine levels in different groups of hematological diseases. It was also found that serotonin levels were significantly lower than those typically measured in peripheral blood as well as many have the influence on stem cells proliferative potential. This paper presents findings from quantitative and statistical analyses of histamine and serotonin levels. Bone marrow collected from patients undergoing routine diagnostic procedures for hematological diseases and receiving inpatient treatment were analyzed. Histamine and serotonin levels were measured using hydrophilic interaction liquid chromatography (HILIC) coupled with tandem mass spectrometry. Obtained data were analyzed statistically and correlated with the diagnosed groups of hematological diseases and the parameters of complete blood counts. Histamine was found in all tested samples, including those from patients without malignancy, and the reported levels were comparable to the reference values in blood. This observation allows us to assume that bone marrow cells can produce and accumulate histamine. Moreover, the statistical analysis revealed a significant relationship between histamine levels and diagnosed mastocytosis, and between histamine levels and myeloproliferative neoplasms. Different results were obtained for serotonin, and its concentrations in most cases were below the limit of quantification of the method used (< 0.2 ng/mL), which can only be compared to peripheral blood plasma. In a few cases, significantly higher serotonin levels were observed and it concerned diseases associated with an increased number of megakaryocytes in the bone marrow.

Toll-like receptor polymorphisms (TLR2 and TLR4) association with the risk of infectious complications in cardiac surgery patients.

BACKGROUND: Postoperative infection is a common healthcare-associated problem, and unfortunately, a serious complication in cardiac surgery patients. Toll-like receptors (TLRs) are crucial in activating non-specific immunity mechanisms and integrating elements of the immune system, due to interactions between specific and non-specific responses. OBJECTIVES: In this study, the association of TLR2 or TLR4 with the risk of postoperative infections in cardiac surgery patients undergoing a coronary artery bypass grafting (CABG) procedures was investigated. MATERIAL AND METHODS: Our research was carried out on a cohort of 299 consecutive adult patients with ischemic heart disease (IHD) who underwent a planned CABG procedure. These patients were monitored for the presence of a postoperative infection over a 30-day observation period. All patients were investigated for 2 TLR2 gene mutations - R753Q (rs5743708) and T16934A (rs4696482), and 2 polymorphisms of the TLR4 gene - D299G (rs4986790) and T399I (rs4986791). The final stage of the study was an evaluation of the hypothetical association between TLR2 and TLR4 gene variances and postoperative infections in patients undergoing CAGB procedures. RESULTS: The prevalence of infections in the final cohort was 15.3% (46/299). The most common infections were surgical site infections, which were diagnosed in 21 patients (45.6%), bloodstream infections in 15 patients (32.6%) and pneumonia in 10 patients (21.8%). Logistic regression demonstrated that the presence of the AG+GG of D299G (rs4986790) and CT+TT of T399I (rs4986791) variants was related to a higher incidence of infection in patients undergoing CAGB procedures. CONCLUSIONS: To our knowledge, this is the first study of its kind to demonstrate that TLR2 and TLR4 mutations affect the risk of post-CABG infections. Being a carrier of the AG+GG of D299G (rs4986790) or CT+TT of T399I (rs4986791), TLR4 variants constitute a postoperative risk factor for infection in patients undergoing CAGB procedures.

Surgical Site Infection in Cardiac Surgery.

Surgical site infections (SSIs) are one of the most significant complications in surgical patients and are strongly associated with poorer prognosis. Due to their aggressive character, cardiac surgical procedures carry a particular high risk of postoperative infection, with infection incidence rates ranging from a reported 3.5% and 26.8% in cardiac surgery patients. Given the specific nature of cardiac surgical procedures, sternal wound and graft harvesting site infections are the most common SSIs. Undoubtedly, DSWIs, including mediastinitis, in cardiac surgery patients remain a significant clinical problem as they are associated with increased hospital stay, substantial medical costs and high mortality, ranging from 3% to 20%. In SSI prevention, it is important to implement procedures reducing preoperative risk factors, such as: obesity, hypoalbuminemia, abnormal glucose levels, smoking and S. aureus carriage. For decolonisation of S. aureus carriers prior to cardiac surgery, it is recommended to administer nasal mupirocin, together with baths using chlorhexidine-based agents. Perioperative management also involves antibiotic prophylaxis, surgical site preparation, topical antibiotic administration and the maintenance of normal glucose levels. SSI treatment involves surgical intervention, NPWT application and antibiotic therapy.

Multidisciplinary aortic arch procedures within the "Aortic Team".

Introduction and aim: The European societies EACTS (European Association for Cardio-Thoracic Surgery) and ESVS (European Society for Vascular Surgery) recommend the establishment of "Aortic Teams" from 2019. In Poland, the first such team was officially established in Specialist University Hospital no. 2 in Szczecin in 2021. Material and methods: Sixty-four patients were treated for aortic arch pathology using frozen elephant trunk (n = 3), branch custom made devices (n = 12), physician-modified endo-grafts (PMEG; n = 30) and the thoracic endovascular aortic repair "plus" technique (n = 19). Results: Among thoracic endovascular aortic repair (TEVAR) plus (chimneys/periscopes, n = 7, extra-anatomical bypasses, n = 12) there was 100% technical success and 4% bad outcomes (stroke or death). Among "customized" stent grafts there were Bolton Relay (n = 8), Brail Endo-Branch (n = 1) and Castor branched stent graft (n = 3) with 91% technical success and 18% bad outcomes. In the group of PMEG there were 14 cases with one fenestration, 5 cases with two fenestrations and 11 cases with triple fenestration to all vessels of the aortic arch. In this group, technical success was achieved in 91% and poor outcome ended treatment in 11%. In total we noted a 91% technical success rate and a good treatment outcome was achieved in 89%. The cooperation of cardiac surgeons and vascular surgeons in one team brought competence benefits for both specialties. It allowed for good clinical and economic results despite new logistical complexities and fits into the currently changing perspective of cardiac surgery development worldwide. Conclusions: Implementation of the recommendation to create aortic teams within cardiac surgery departments is possible and may be cost-effective in Polish conditions.

Elastography of Endometrium in Women Taking Tamoxifen: A New Approach to an Old Diagnostic Problem.

Tamoxifen is a commonly used selective estrogen receptor modulator applied in the treatment for breast cancer. However, in the endometrium, Tamoxifen stimulates tissue growth, cellular transformation, the migration of the cells, and metastatic potential in endometrial cancer. Considering that uterine cancer is the most common neoplasm of the reproductive tract and the third most common neoplastic disease in women, the aim of this study was to investigate if applying elastography in examining the endometrium was beneficial for uterine cancer screening protocols in women on selective estrogen receptor modulator therapy. This study was based on the execution of a classic assessment of the endometrium that included the evaluation of the following: echogenicity, central endometrial stripe, presence of fluid in the uterine lumen, myometrium-endometrium interface, intensity of vascularization and vascular pattern. An ultrasound presentation was then processed and analyzed with elastography. The values of the elastography parameters demonstrated good consistency for the measurement of the softest endometrial layer thickness in elastography. A strong positive correlation (R = 0.56) was demonstrated between the endometrial thickness, as determined by ultrasound examination, and the softest endometrial layer in elastography (p < 0.001). The research showed that the elastography measurements of the width of the softest endometrium layer, based on a population of women taking Tamoxifen, appeared to be a promising option for endometrial cancer screening.

Current Evidence Regarding Biomarkers Used to Aid Postoperative Delirium Diagnosis in the Field of Cardiac Surgery-Review.

Postoperative cognitive disorders after cardiac surgery may manifest as postoperative delirium (POD) or later as postoperative cognitive dysfunction (POCD). The incidence of POD after cardiac surgery ranges from 16% to 73%. In contrast to POD, POCD is usually diagnosed after the discharge from hospital, with an incidence of 30 to 70% of cases, very often noticed only by close relative or friends, decreasing after six (20-30%) and twelve (15-25%) months after surgery. Perioperative cognitive disorders are associated with adverse short- and long-term effects, including increased morbidity and mortality. Due to the complexity of delirium pathomechanisms and the difficulties in the diagnosis, researchers have not yet found a clear answer to the question of which patient will be at a higher risk of developing delirium. The risk for POD and POCD in older patients with numerous comorbidities like hypertension, diabetes, and previous ischemic stroke is relatively high, and the predisposing cognitive profile for both conditions is important. The aim of this narrative review was to identify and describe biomarkers used in the diagnosis of delirium after cardiac surgery by presenting a search through studies regarding this subject, which have been published during the last ten years. The authors discussed brain-derived biomarkers, inflammation-related biomarkers, neurotransmitter-based biomarkers, and others. Work based on inflammation-related biomarkers, which are characterized by the low cost of implementation and the effectiveness of delirium diagnosis, seems to be the closest to the goal of discovering an inexpensive and effective marker. Currently, the use of a panel of tests, and not a single biomarker, brings us closer to the discovery of a test, or rather a set of tests ideal for the diagnosis of delirium after cardiac surgery.

Postoperative Delirium in Patients with Chronic Obstructive Pulmonary Disease after Coronary Artery Bypass Grafting.

BACKGROUND AND OBJECTIVES: The incidence of postoperative delirium (POD) in patients with chronic obstructive pulmonary disease (COPD) is unclear. It seems that postoperative respiratory problems that may occur in COPD patients, including prolonged mechanical ventilation or respiratory-tract infections, may contribute to the development of delirium. The aim of the study was to identify a relationship between COPD and the occurrence of delirium after cardiac surgery and the impact of these combined disorders on postoperative mortality. MATERIALS AND METHODS: We performed an analysis of data collected from 4151 patients undergoing isolated coronary artery bypass grafting (CABG) in a tertiary cardiac-surgery center between 2012 and 2018. We included patients with a clinical diagnosis of COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. The primary endpoint was postoperative delirium; Confusion Assessment Method in the Intensive Care Unit (CAM-ICU) was used for delirium assessment. RESULTS: Final analysis included 283 patients with COPD, out of which 65 (22.97%) were diagnosed with POD. Delirious COPD patients had longer intubation time (p = 0.007), more often required reintubation (p = 0.019), had significantly higher levels of C-reactive protein (CRP) three days after surgery (p = 0.009) and were more often diagnosed with pneumonia (p < 0.001). The CRP rise on day three correlated positively with the occurrence of postoperative pneumonia (r = 0.335, p = 0.005). The probability of survival after CABG was significantly lower in COPD patients with delirium (p < 0.001). CONCLUSIONS: The results of this study confirmed the relationship between chronic obstructive pulmonary disease and the incidence of delirium after cardiac surgery. The probability of survival in COPD patients undergoing CABG who developed postoperative delirium was significantly decreased.

The parameters of carotid plaques' calcifications and clinical nature of the lesions in the context of revascularization treatment. The enlargement of calcifications is still the most important.

INTRODUCTION: It remains a challenge to determine criteria according to which patients with asymptomatic carotid stenosis could be properly qualified for revascularization treatment. Carotid calcification assessment seems to be here quite attractive. The aim of the study was the histological analysis of various parameters of calcifications in human carotid plaques in relation to the symptomatic/asymptomatic nature of the lesions. MATERIAL AND METHODS: The study involved carotid plaques taken from patients who have undergone endarterectomy of the internal carotid artery. RESULTS: Calcified plaques (with enlarged calcifications) were significantly more frequently asymptomatic than non-calcified plaques. The remaining calcification characteristics played no role. Calcified lesions disclosed the dominance of the fibrous component and the small lipid core significantly more frequently than non-calcified plaques. The percentage of females in the patients group with calcified lesions was significantly higher than in the group with non-calcified plaques. The percentage of males was lower. The former patients group used statins and angiotensin inhibitors significantly more frequently than patients with non-calcified plaques. Enlarged calcifications were independently associated with the asymptomatic nature of the carotid plaques. CONCLUSIONS: The enlargement of calcifications in carotid plaques is the only calcification parameter important for the clinical outcome of carotid atherosclerosis. Patients with calcified carotid plaques have a significantly lower risk of ischemic stroke than patients with non-calcified lesions.

Balancing intubation time with postoperative risk in cardiac surgery patients - a retrospective cohort analysis.

INTRODUCTION: Intubation time in patients undergoing cardiac surgery may be associated with increased mortality and morbidity. Premature extubation can have serious adverse physiological consequences. The aim of this study was to determine the influence of intubation time on morbidity and mortality in patients undergoing cardiac surgery. METHODS: We performed a retrospective analysis of data on 1,904 patients undergoing isolated coronary artery bypass grafting (CABG) and stratified them by duration of intubation time after surgery - 0-6, 6-9, 9-12, 12-24 and over 24 hours. Postoperative complications risk analysis was performed using multivariate logistic regression analysis for patients extubated ≤12 and >12 hours. RESULTS: Intubation percentages in each time cohort were as follows: 0-6 hours - 7.8%, 6-9 hours - 17.3%, 9-12 hours - 26.8%, 12-24 hours - 44.4% and >24 hours - 3.7%. Patients extubated ≤12 hours after CABG were younger, mostly males, more often smokers, with lower preoperative risk. They had lower 30-day mortality (2.02% vs 4.59%, P=0.002), shorter hospital stay (7.68±4.49 vs 9.65±12.63 days, P<0.001) and shorter intensive care unit stay (2.39 vs 3.30 days, P<0.001). Multivariate analysis showed that intubation exceeding 12 hours after CABG increases the risk of postoperative delirium (OR 1.548, 95% CI 1.161-2.064, P=0.003) and risk of postoperative hemofiltration (OR 1.302, 95% CI 1.023-1.657, P=0.032). CONCLUSION: Results indicate that risk of postoperative complications does not increase until intubation time exceeds 12 hours. Shorter intubation time is seen in younger, men and smokers. Intubation time >12 hours is a risk factor for postoperative delirium and hemofiltration after cardiac surgery.

Validation of the behavioral pain scale to assess pain intensity in adult, intubated postcardiac surgery patients: A cohort observational study - POL-BPS.

Patients after cardiac surgery experience significant pain, but cannot communicate effectively due to opioid analgesia and sedation. Identification of pain with validated behavioral observation tool in patients with limited abilities to self-report pain improves quality of care and prevents suffering. Aim of this study was to validate Polish version of behavioral pain scale (BPS) in intubated, mechanically ventilated patients sedated with dexmedetomidine and morphine after cardiac surgery.Prospective observational cohort study included postoperative cardiac surgery patients, both sedated with dexmedetomidine and unsedated, observed at rest, during a nociceptive procedure (position change) and 10 minutes after intervention. Pain control was achieved using morphine infusion and nonopioid coanalgesia. Pain intensity evaluation included self-report by patient using numeric rating scale (NRS) and BPS assessments carried out by 2 blinded observers.A total of 708 assessments were performed in 59 patients (mean age 68 years), predominantly men (44/59, 75%). Results showed very good interrater correlation between raters (interrater correlation scores >0.87). Self-report NRS scores were obtained from all patients. Correlation between NRS and BPS was relatively strong during nociceptive procedures in all patients for rater A and rater B (Spearman R > 0.65, P < .001). Both mean NRS and BPS scores were significantly higher during nociceptive procedures as compared to assessments at rest, in both sedated and unsedated patients (P < .001).The results of this observational study show that the Polish translation of BPS can be regarded as a useful and validated tool for pain assessment in adult intubated patients. This instrument can be used in both unsedated and sedated cardiac surgery patients with limited communication abilities.

Predisposition of functional genetic variants of A-kinase anchoring protein 10 toward acquired repolarization disorders in high-risk vascular surgery patients.

PURPOSE: We aimed at assessing the predisposition of A-kinase anchoring protein 10 (AKAP10) polymorphism toward acquired repolarization disorders in high-risk vascular surgery patients. PATIENTS AND METHODS: One hundred adult patients (age =44-85 years), scheduled for an elective high-risk "open" vascular surgery procedure, were recruited. The electrocardiogram Holter monitor was used to assess repolarization stability from the beginning of the operation up to 24 hours afterward. The AKAP10 gene rs203462 polymorphism and cardiac complications were analyzed. RESULTS: Repolarization disturbances defined as QT interval duration corrected for heart rate (QTc) interval prolongation >500 ms and QTc interval dispersion >65 ms were recorded in 46 patients. A model of multivariate logistic regression showed that only the presence of allele G of the AKAP10 polymorphism was an independent risk factor for repolarization disturbances in the perioperative period (odds ratio =14.35; 95% CI =4.65-44.23; p<0.0001). CONCLUSION: When the acquired QTc interval prolongation or QTc dispersion is associated with AKAP10 polymorphism, it may remain clinically silent.

Iron excretion in urine in patients with acute kidney injury after cardiac surgery.

BACKGROUND: Hemolysis during cardiopulmonary bypass may lead to acute kidney injury caused by an excessive amount of iron. The clinical usefulness of the measurement of total iron concentration in the urine with the use of the atomic absorption spectrometry method for early identification of patients with postoperative acute kidney injury is not well-established. OBJECTIVES: An observational, prospective study was conducted on a group of 88 pre-selected adult patients undergoing a planned coronary artery bypass grafting (CABG) procedure. MATERIAL AND METHODS: The amount and concentrations of total iron, creatinine and neutrophil gelatinaseassociated lipocalin (NGAL) were evaluated in urine samples. A comparative analysis of the evaluated biochemical parameters was performed in regard to the occurrence of acute kidney injury 48 h postoperatively. RESULTS: Patients in the acute kidney injury group presented more advanced age (p = 0.01), preoperative myocardial infarction (p = 0.02), diuresis reduction (p = 0.04), and lower total iron levels in the 48-hour urine sample (p = 0.01). There was no difference when considering iron concentration in single urine samples in the study group. CONCLUSIONS: The sole result of total iron concentration in single urine samples is unreliable for the diagnosis of acute kidney injury after cardiac surgery. Decreased excretion of iron in the urine seems to be an important additional element in the multifactorial pathogenesis of acute postoperative kidney failure.

Early delirium after cardiac surgery: an analysis of incidence and risk factors in elderly (≥65 years) and very elderly (≥80 years) patients.

INTRODUCTION: Postoperative delirium is a common complication of cardiac surgery associated with increased mortality, morbidity, and long-term cognitive dysfunction. The aim of this study was to identify incidence and risk factors of delirium in elderly (≥65 years) and very elderly (≥80 years) patients undergoing major cardiac surgery. MATERIALS AND METHODS: We performed a retrospective cohort analysis of prospectively collected data from a register of the cardiac surgery department of a tertiary referral university hospital between 2014 and 2016. Analysis was performed in two groups, ≥65 years and ≥80 years. RESULTS: We analyzed 1,797 patients ≥65 years, including 230 (7.24%) patients ≥80 years. Delirium was diagnosed in 21.4% (384/1,797) of patients above 65 years, and in 33.5% (77/230) of octogenarians. Early mortality did not differ between patients with and without delirium. Intensive care unit (ICU) stay (p<0.001), hospital stay (p<0.001), and intubation time (p=0.002) were significantly longer in patients undergoing cardiac surgery ≥65 years with delirium. According to multivariable analysis, <65 years, age (odds ratio [OR] 1.036, p=0.002), low ejection fraction (OR 1.634, p=0.035), diabetes (1.346, p=0.019), and extracardiac arteriopathy (OR 1.564, p=0.007) were found to be independent predictors of post-cardiac surgery delirium. Postoperative risk factors for developing delirium ≥65 years were atrial fibrillation (1.563, p=0.001), postoperative pneumonia (OR 1.896, p=0.022), elevated postoperative creatinine (OR 1.384, p=0.004), and prolonged hospitalization (OR 1.019, p=0.009). CONCLUSION: Patients above 65 years of age with postoperative delirium have poorer outcome and are more likely to have prolonged hospitalization and ICU stay, and longer intubation times, but 30-day mortality is not increased. In our study, eight independent risk factors for development of post-cardiac surgery delirium were age, low ejection fraction, diabetes, extracardiac arteriopathy, postoperative atrial fibrillation, pneumonia, elevated creatinine, and prolonged hospitalization time.

Cardiac surgery related cardio-renal syndrome assessed by conventional and novel biomarkers - under or overestimated diagnosis?

INTRODUCTION: Serum creatinine is a 'gold standard' criterion of recognizing and staging of acute kidney injury (AKI) despite it being a suboptimal, delayed indicator. The interpretation of increased values of biomarkers imposes great difficulty regarding cardiac surgery procedures performed with cardiopulmonary bypass and may lead to under- or overestimated diagnosis. The aim of this study was to evaluate the clinical utility of the sole serum creatinine or urine neutrophil gelatinase-associated lipocalin (NGAL) concentration used for identification of patients with AKI after cardiac surgery. MATERIAL AND METHODS: A prospective observational study was conducted on a group of 88 adult patients undergoing a coronary artery bypass grafting procedure. Serum creatinine was evaluated on the day of the operation, and 24 and 48 h post-operatively. Urinary NGAL concentration was measured: immediately after and one hour after cardiopulmonary bypass, and 24 h from the beginning of the operation. We assessed features of kidney injury and 30-day and 5-year mortality. RESULTS: Patients in the AKI group diagnosed with creatinine level and urine output criteria presented more advanced age (p = 0.01), higher body mass index (p = 0.01) and preoperative myocardial infarction (p = 0.02). Elevation of NGAL level was observed in 5 of 13 cases with AKI, based on creatinine criteria and 4 of 75 cases without AKI. Within 5 years after the surgical procedure the recurrence of renal failure was 36% in the AKI group (with perioperative NGAL elevation in 2 cases only). CONCLUSIONS: In the cardiac surgery patients the diagnosis of AKI based on sole serum creatinine or urine NGAL concentration confirmed transient kidney injury. However, the clinical implications of these findings are insufficient for prediction of clinical outcome.

Relationship between toll-like receptor 2 R753Q and T16934A polymorphisms and Staphylococcus aureus nasal carriage.

BACKGROUND: The association among specific single-nucleotide polymorphisms (SNPs) in TLR2 R753Q (rs5743708) and T16934A (rs4696480) and the nasal carriage of Staphylococcus aureus was studied in adults before CABG. METHODS: The TLR2 polymorphisms were genotyped in 299 consecutive patients prepared for a CABG operation. Genotyping was performed using restriction fragment length polymorphism (RFLP) analysis of PCR-amplified fragments. Two nasal swab cultures were taken within 2 weeks before the operation. Subjects were classified as Staphylococcus aureus carriers if at least one culture was positive while those patients with both cultures found to be negative were classified as non-carriers. RESULTS: The prevalence of nasal S. aureus carriage in the final cohort was 22.1% (66/299), while no MRSA was detected in our study group. No significant differences in the TLR2 polymorphisms were observed between the study and the control groups. No associations were found between TLR2 haplotypes and the covariates of age, sex, NYHA, weight, height, BMI, CAD, smoking status and ESlog score. No differences were found between carriers and noncarriers regarding the allelic distribution of the TLR2 T-16934A SNP. Almost 93% of the patients who were screened for the presence of the TLR2 Arg753Gln (rs5743708) were GG wild type homozygous. Twenty one subjects from the study group (7.1%) were GA heterozygous, while no patient in either group was homozygous for the TLR2 Arg753Gln (rs5743708) mutation. TLR2 Arg753Gln genotyping showed that GA heterozygous patients were detected more frequently in the group of Staphylococcus aureus nasal carriers than in non-carrier adults. CONCLUSION: Our results suggest that the carrier status for the GA variant of the TLR2 Arg753Gln (rs5743708) polymorphism may be a risk factor for Staphylococcus aureus carriage.

Electrophysiological, hemodynamic, and metabolic response to open procedure or endovascular repair of infrarenal aortic aneurysms.

BACKGROUND: The occurrence of cardiovascular diseases in the group of patients undergoing vascular surgery because of abdominal aorta aneurysm is very high. Endovascular procedures are regarded as hemodynamically safer for the patients. The aim of this study was to compare the changes in electrophysiological, hemodynamic, and metabolic parameters depending on the type of operation, using invasive hemodynamic monitoring and Holter electrocardiography recording. METHODS: A prospective, observational, nonrandomized study was conducted to compare dynamic changes of electrophysiological parameters (dominant rhythm, arrhythmia, corrected QT interval (QTc), invasive blood pressure, electrolytes, and acid-base balance in defined points during perioperative time in 2 groups: vascular prosthesis implantation group (91 patients) and stent-graft implantation group (83 patients). RESULTS: The study group comprised 174 consecutive adult Caucasian patients (mean age 64.4 ± 8.9 years in stent-graft group and 70.0 ± 7.5 years in vascular prosthesis implantation group). Although patients in the stent-graft implantation group were younger, they were diagnosed with lower limbs vascular atherosclerosis, type 2 diabetes mellitus, and a lower left ventricle ejection fraction more often than patients in the open procedure group. During the open procedure, higher blood pressure amplitudes (P = 0.00009), higher decrease in pH (P = 0.049), increase in the arterial lactate level (P = 0.00002), prolonged QTc values (P = 0.001), more frequent ventricular extrasystoles (P = 0.005), and cardiovascular deaths were observed, when compared with those observed during the endovascular aneurysm repair. CONCLUSIONS: When compared with the chosen techniques, the one for infrarenal abdominal aneurysm was found to be associated with significant differences in electrophysiological, hemodynamic, and metabolic parameters.