Relation of Prolonged Pacemaker Dependency After Cardiac Surgery to Mortality.

Permanent pacemaker implantation (PPI) represents a rare complication after cardiac surgery, with no uniform agreement on timing and no information on follow-up. A multicenter retrospective study was designed to assess pacemaker dependency (PMD) and long-term mortality after cardiac surgery procedures. Between 2004 and 2016, PPI-patients from 18 centers were followed. Time-to-event data were evaluated with semiparametric regression Cox models and semiparametric Fine and Gray model for competing risk framework. Of 859 (0.90%) PPI-patients, 30% were pacemaker independent (PMI) at 6 months. PMD showed higher mortality compared with PMI (10-year survival 80.1% ± 2.6% and 92.2% +2.4%, respectively, log-rank p-value < 0.001) with an unadjusted hazard ratio for death of 0.36 (95% CI 0.20 to 0.65, p< 0.001 favoring PMI) and an adjusted hazard ratio of 0.19 (95% CI 0.08 to 0.45, p< 0.001 with PMD as reference). Crude cumulative incidence function of restored PMI rhythm at follow-up at 6 months, 1 year and 12 years were 30.5% (95% CI 27.3% to 33.7%), 33.7% (95% CI 30.4% to 36.9%) and 37.2% (95% CI 33.8% to 40.6%) respectively. PMI was favored by preoperative sinus rhythm with normal conduction (SR) (HR 2.37, 95% CI 1.65 to 3.40, p< 0.001), whereas coronary artery bypass grafting and aortic valve replacement were independently associated with PMD (HR 0.63, 95% CI 0.45 to 0.88, p = 0.006 and HR 0.807, 95% CI 0.65 to 0.99, p = 0.047 respectively). Time-to-implantation was not associated with increased rate of PMI. Although 30% of PPI-patients are PMI after 6 months, PMD is associated with higher mortality at long term.

The role of orthopaedic trainees during the COVID-19 pandemic and impact on post-graduate orthopaedic education: a four-nation survey of over 100 orthopaedic trainees.

AIMS: The COVID-19 pandemic has had a significant impact on the provision of orthopaedic care across the UK. During the pandemic orthopaedic specialist registrars were redeployed to "frontline" specialties occupying non-surgical roles. The impact of the COVID-19 pandemic on orthopaedic training in the UK is unknown. This paper sought to examine the role of orthopaedic trainees during the COVID-19 and the impact of COVID-19 pandemic on postgraduate orthopaedic education. METHODS: A 42-point questionnaire was designed, validated, and disseminated via e-mail and an instant-messaging platform. RESULTS: A total of 101 orthopaedic trainees, representing the four nations (Wales, England, Scotland, and Northern Ireland), completed the questionnaire. Overall, 23.1% (23/101) of trainees were redeployed to non-surgical roles. Of these, 73% (17/23) were redeployed to intensive treatment units (ITUs), 13% (3/23) to A/E, and 13%(3/23%) to general medicine. Of the trainees redeployed to ITU 100%, (17/17) received formal induction. Non-deployed or returning trainees had a significant reduction in sessions. In total, 42.9% (42/101) % of trainees were not timetabled into fracture clinic, 53% (53/101) of trainees had one allocated theatre list per week, and 63.8%(64/101) of trainees did not feel they obtained enough experience in the attached subspecialty and preferred repeating this. Overall, 93% (93/101) of respondents attended at least one weekly online webinar, with 79% (79/101) of trainees rating these as useful or very useful, while 95% (95/101) trainees attended online deanery teaching which was rated as more useful than online webinars (p = 0.005). CONCLUSION: Orthopaedic specialist trainees occupied an important role during the COVID-19 pandemic. COVID-19 has had a significant impact on orthopaedic training. It is imperative this is properly understood to ensure orthopaedic specialist trainees achieve competencies set out in the training curriculum.Cite this article: Bone Joint Open 2020;1-11:676-682.

Trauma surgery at a designated COVID-19-free site during the pandemic: a safe model and a possible way to restart routine elective surgery.

AIMS: Elective operating was halted during the COVID-19 pandemic to increase the capacity to provide care to an unprecedented volume of critically unwell patients. During the pandemic, the orthopaedic department at the Aneurin Bevan University Health Board restructured the trauma service, relocating semi-urgent ambulatory trauma operating to the isolated clean elective centre (St. Woolos' Hospital) from the main hospital receiving COVID-19 patients (Royal Gwent Hospital). This study presents our experience of providing semi-urgent trauma care in a COVID-19-free surgical unit as a safe way to treat trauma patients during the pandemic and a potential model for restarting an elective orthopaedic service. METHODS: All patients undergoing surgery during the COVID-19 pandemic at the orthopaedic surgical unit (OSU) in St. Woolos' Hospital from 23 March 2020 to 24 April 2020 were included. All patients that were operated on had a telephone follow-up two weeks after surgery to assess if they had experienced COVID-19 symptoms or had been tested for COVID-19. The nature of admission, operative details, and patient demographics were obtained from the health board's electronic record. Staff were assessed for sickness, self-isolation, and COVID-19 status. RESULTS: A total of 58 surgical procedures were undertaken at the OSU during the study period; 93% (n = 54) of patients completed the telephone follow-up. Open reduction and internal fixation of ankle and wrist fractures were the most common procedures. None of the patients nor members of their households had developed symptoms suggestive of COVID-19 or required testing. No staff members reported sick days or were advised by occupational health to undergo viral testing. CONCLUSION: This study provides optimism that orthopaedic patients planned for surgery can be protected from COVID-19 nosocomial transmission at separate COVID-19-free sites.Cite this article: Bone Joint Open 2020;1-6:302-308.

Stress and Anxiety Management During the COVID-19 Pandemic (Lessons Learnt from a Cohort of Orthopaedic Registrars Redeployed to ITU).

BACKGROUND: Working during the coronavirus pandemic has had a significant impact on health care workers. A group of orthopaedic trainees at Royal Gwent Hospital, UK, were redeployed to intensive therapy unit for four weeks during COVID-19 pandemic. This study reviews our experience; focusing on causes of stress and anxiety, and how they were managed. The lessons learnt could be used as a framework for pre-emptive me-asures during future challenges. MATERIAL AND METHODS: Orthopaedic registrars were divided into two groups. Seven trainees (Redeployed group) moved to ITU for four weeks to support the critical care team. The other group (Retained group) of eight registrars continued to cover orthopaedic rota. A survey was done for anxiety levels comparing the two groups at three time points during these four weeks. RESULTS: Anxiety and stress in the ITU-redeployed group was comparatively less than the continuing group as time progressed during the redeployment. CONCLUSIONS: 1. The disruptive impact of the COVID-19 pandemic has been a source of massive stress and an-xiety for health care workers. 2. Our experience shows that stress is controllable with the correct strategies. 3. The main points are early identification of vulnerable groups, proper induction, active involvement, adequate explanation, appreciation, good communication, and available psychological support whenever needed. 4. These are essential to maintain a resilient workforce against upcoming waves of COVID-19.

Non-steroidal anti-inflammatory drug effects on renal and cardiovascular function: from physiology to clinical practice.

Excessive or inappropriate use of non-steroidal anti-inflammatory drugs can affect cardiovascular and renal function. Non-steroidal anti-inflammatory drugs, both non-selective and selective cyclooxygenase 2 inhibitors, are among the most widely used drugs, especially in the elderly, with multiple comorbidities. Exposition to a polypharmacy burden represents a favourable substrate for the onset of non-steroidal anti-inflammatory drug-induced deleterious effects. Cardiovascular and renal issues concerning the occurrence of myocardial infarction, atrial fibrillation, heart failure and arterial hypertension, as well as acute or chronic kidney damage, become critical for clinicians in their daily practice. We discuss current available knowledge regarding prostanoid physiology in vascular, cardiac and renal systems, pointing out potential negative non-steroidal anti-inflammatory drug-related issues in clinical practice.

A randomized clinical trial of ultrasound-guided infra-clavicular cannulation of the subclavian vein in cardiac surgical patients: short-axis versus long-axis approach.

PURPOSE: The aim of this study was to compare the success rate and safety of short-axis versus long-axis approaches to ultrasound-guided subclavian vein cannulation. METHODS: A total of 190 patients requiring central venous cannulation following cardiac surgery were randomized to either short-axis or long-axis ultrasound-guided cannulation of the subclavian vein. Each cannulation was performed by anesthesiologists with at least 3 years' experience of ultrasound-guided central vein cannulation (>150 procedures/year, 50% short-axis and 50% long-axis). Success rate, insertion time, number of needle redirections, number of separate skin or vessel punctures, rate of mechanical complications, catheter misplacements, and incidence of central line-associated bloodstream infection were documented for each procedure. RESULTS: The subclavian vein was successfully cannulated in all 190 patients. The mean insertion time was significantly shorter (p = 0.040) in the short-axis group (69 ± 74 s) than in the long-axis group (98 ± 103 s). The short-axis group was also associated with a higher overall success rate (96 vs. 78%, p < 0.001), first-puncture success rate (86 vs. 67%, p = 0.003), and first-puncture single-pass success rate (72 vs. 48%, p = 0.002), and with fewer needle redirections (0.39 ± 0.88 vs. 0.88 ± 1.15, p = 0.001), skin punctures (1.12 ± 0.38 vs. 1.28 ± 0.54, p = 0.019), and complications (3 vs. 13%, p = 0.028). CONCLUSIONS: The short-axis procedure for ultrasound-guided subclavian cannulation offers advantages over the long-axis approach in cardiac surgery patients.

Internal Jugular Vein Complete Thrombosis After Dual Chamber Pacemaker Implant.

Venous thrombosis after pacemaker implant is a known, although often underrecognized condition that can challenge system revision or upgrading, leading occasionally to thromboembolic complications. Several factors are considered to promote thrombus formation. Among them, alteration of blood flow mechanics due to the presence of catheters in the vessel lumen may itself play a pivotal role. Hereby we present the case of a 65-year old men who underwent a dual-chamber pacemaker implant in another institute for sick sinus syndrome by means of left cephalic venous access. About two months later he started experiencing neck swelling, pain and dysphagia. Six months later, ultrasonography and CT-scan revealed complete jugular vein thrombosis caused by a lead loop at the level of the left subclavian vein. Of note, thrombosis occurred despite proper oral anticoagulation with warfarin undertaken for coexisting atrial fibrillation. It's important to keep in mind this possible complication of pacemaker implant to allow for early diagnosis and better treatment chances. This case report is an example of how proximal catheter displacement may promote thrombus formation, probably by affecting blood flow mechanics, even in spite of proper oral anticoagulation.

Correlation between quality of cardiopulmonary resuscitation and self-efficacy measured during in-hospital cardiac arrest simulation; preliminary results.

BACKGROUND: The concept of self-assess it's a central mechanism in human agency for behavior change and should translate to desirable practice patterns. There are no many studies that have investigated the relationship between the perception of the ability to perform cardiopulmonary resuscitation (CPR) and the quality of the same. The aim of this work is to investigate the relation between physiological and psychosocial variables in cardiac resuscitation in order to improve the involvement and motivation of professionals in training courses. METHODS: During the year 2012, 322 medical staff of Ospedale-Universitario of Parma were trained to basic life support defibrillation (BLSD). Before started the course the partecipants were randomly selected among the staff working in the same department to create a team of two persons and involved in a simulation that reproduced the first five minutes that occurs for a cardiac arrest in a medical or surgical department in our hospital before the intervention of the hospital emergency team. Before and after simulation to each participant was asked to answer a self-efficacy questionnaire on a 10-point scale on the management of cardiac. During simulation were registered the activation time of the emergency response system, hands-on time, defibrillation time, number of compression and correct compression rate. RESULTS: Activation time of the emergency response system was 70.52 ± 78.77 seconds. In 55 teams was not made the allert. The defibrillation time was 148.63 ± 58.43 seconds. In 44 teams the defibrillator were used within 120 seconds, in 36 (22.1%) it was not used. Hands-on time average was of 166.20 ± 62.9 seconds. The mean number of compression was 216.22 ± 115.57. The percentage of satisfactory compression was 9.97 ± 21.23 %. The level of self-efficacy was under the average for the 35.6%, while the 26.8% of the participants had a medium level of 5 and the 38.5% of the sample declared to feel an efficacy level included in 6-10. The sense of self efficacy after the simulation was constant in the 38.3% of the sample, while increased in the 30.5% and decreased in the 31.2%. We found no significant correlations between self-efficacy levels and specific results in scenario acting before simulation, instead, after the simulation the skills performances are much more correlated with self-efficacy. CONCLUSIONS: The medical staff reported an individual's perception of good efficacy in the management of simulation of cardiac arrest, but it does not correspond to a high skills. An open question is if and how these psychosocial variables may play a role in improving the quality of CPR and if knowledge of the low capacity to manage a cardiac arrest can be translated into the need for the medical staff to be regularly engaged in BLSD retraining.

Dizziness and syncope in young people: keep your mind open! Case report of the challenging differentiation between arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) and catecholaminergic polymorphic ventricular tachycardia (CPVT).

A paradigmatic case of aborted sudden cardiac death (SCD) in a young man is discussed, mirroring the challenge of diagnosing the various conditions potentially underlying this dramatic condition. Based on the clinical characteristics of our case, presenting some overlapping clinical features common to both the diseases, the discussion will be focused on Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) and Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia (ARVC/D). Epidemiological, genetic, diagnostic and therapeutic aspect will be discussed.

Adenosine-induced severe bronchospasm in a patient without pulmonary disease.

Adenosine is widely used for the treatment of supraventricular tachycardias for its efficacy and excellent safety, but it has been reported to precipitate severe bronchospasm in patients with pulmonary disease. The drug is therefore contraindicated in asthmatic subjects and should be used with caution in patients with chronic obstructive pulmonary disease. Nevertheless, true bronchospasm is rare and should be distinguished from the much more common occurrence of dyspnea, only as a symptom and without respiratory compromise, which is benign and transient. We describe the occurrence of severe bronchospasm following adenosine administration for a supraventricular tachycardia in a young male without any history of pulmonary disease. To our knowledge, this is the first time such complication is reported in a subject without lung disease. The patient arrived at the emergency department for palpitations with a regular wide QRS tachycardia with a left bundle-branch block morphology. Sinus carotid massage was unsuccessful, and 2 intravenous adenosine boluses were given without effect. A further 12-mg bolus cardioverted the patient, who became increasingly dyspneic and hypoxic, with diffuse bronchospasm. An urgent chest radiograph had normal results. He was treated with oxygen and inhaled and intravenous steroids, but dyspnea and bronchospasm resolved only after intravenous aminophylline. The arrhythmia recurred and was finally terminated by intravenous flecainide. Although dyspnea after adenosine administration is usually a transient, benign phenomenon, physicians should be alert to the presence of objective signs of respiratory distress, which should prompt immediate treatment, even in subjects without previous history of pulmonary disease.