Factor Eight Inhibitor Bypassing Activity as First-line Therapy for Coagulopathy in Cardiac Surgery.

OBJECTIVES: To compare the outcomes of factor eight inhibitor bypassing activity (FEIBA) versus fresh frozen plasma (FFP) as the primary treatment for postoperative coagulopathy in patients undergoing cardiac surgery. DESIGN: A retrospective, propensity-matched study. SETTING: A single, tertiary hospital. PARTICIPANTS: Patients who underwent noncoronary cardiac surgery with cardiopulmonary bypass between 2015 and 2023. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We stratified patients into 2 groups based on whether they received intraoperative FFP or FEIBA; cases using both were excluded. We analyzed 434 cases, with 197 receiving FFP and 237 receiving FEIBA. After propensity matching, there was no significant difference in the proportion of the patients who required packed red blood cell transfusions (p = 0.08). However, of those who required packed red blood cell transfusions, patients in the FEIBA group required significantly fewer units of packed red blood cells (p < 0.001). Significantly fewer patients in the FEIBA group required platelet (p < 0.001) and cryoprecipitate (p < 0.001) transfusions. The FEIBA group showed decreased prolonged postoperative intubation (p = 0.05), decreased intensive care unit length of stay (p = 0.04), and lower 30-day readmission rates (p = 0.03). There were no differences in the rates of thrombotic complications between the 2 cohorts. CONCLUSIONS: In the initial treatment of postcardiopulmonary bypass coagulopathy, FEIBA may be more effective than FFP in decreasing blood product transfusions and readmission rates. Further studies are needed to explore the potential routine use of FEIBA as first-line agent in this patient population.

Site-specific effects of dobutamine on cardiac conduction and refractoriness.

BACKGROUND: Isoproterenol, a non-specific beta agonist, is commonly used during electrophysiology studies (EPS). However, with the significant increase in the price of isoproterenol in 2015 and the increasing number of catheter ablations performed, the cost implications cannot be ignored. Dobutamine is a less expensive synthetic compound developed from isoproterenol with a similar mechanism to enhance cardiac conduction and shorten refractoriness, thus making it a feasible substitute with a lower cost. However, the use of dobutamine for EPS has not been well-reported in the literature. OBJECTIVE: To determine the site-specific effects of various doses of dobutamine on cardiac conduction and refractoriness and assess its safety during EPS. METHODS: From February 2020 to October 2020, 40 non-consecutive patients scheduled for elective EPS, supraventricular tachycardia, atrial fibrillation, and premature ventricular contraction ablations at a single center were consented and prospectively enrolled to assess the effect of dobutamine on the cardiac conduction system. At the end of each ablation procedure, measures of cardiac conduction and refractoriness were recorded at baseline and with incremental doses of dobutamine at 5, 10, 15, and 20 mcg/kg/min. For the primary analysis, the change per dose of dobutamine from baseline to each dosing level of dobutamine received by the patients, comparing atrioventricular node block cycle length (AVNBCL), ventricular atrial block cycle length (VABCL) and sinus cycle length (SCL), was tested using mixed-effect regression. For the secondary analysis, dobutamine dose level was tested for association with relative changes from baseline of each electrophysiologic parameter (SCL, AVNBCL, VABCL, atrioventricular node effective refractory period (AVNERP), AH, QRS, QT, QTc, atrial effective refractory period (AERP), ventricular effective refractory period (VERP), using mixed-effect regression. Changes in systolic and diastolic blood pressures were also assessed. The Holm-Bonferroni method was used to adjust for multiple testing. RESULTS: For the primary analysis there was no statistically significant change of AVNBCL and VABCL relative to SCL from baseline to each dose level of dobutamine. The SCL, AVNBCL, VABCL, AVNERP, AERP, VERP and the AH, and QT intervals all demonstrated a statistically significant decrease from baseline to at least one dose level with incremental dobutamine dosing. Two patients (5%) developed hypotension during the study and one patient (2.5%) received a vasopressor. Two patients (5%) had induced arrhythmias but otherwise no major adverse events were noted. CONCLUSION: In this study, there was no statistically significant change of AVNBCL and VABCL relative to SCL from baseline to any dose level of dobutamine. As expected, the AH and QT intervals, and the VABCL, VERP, AERP and AVNERP all significantly decreased from baseline to at least one dose level with an escalation in dobutamine dose. Dobutamine was well-tolerated and safe to use during EPS.

Impact of Limited Enhanced Recovery Pathway for Cardiac Surgery: A Single-Institution Experience.

OBJECTIVES: Enhanced recovery pathway (ERP) refers to extensive multidisciplinary, evidence-based pathways used to facilitate recovery after surgery. The authors assessed the impact that limited ERP protocols had on outcomes in patients undergoing cardiac surgery at their institution. DESIGN: A retrospective cohort study. SETTING: This study was a single-institution study conducted at a university hospital. PARTICIPANTS: Patients undergoing open adult cardiac surgery. INTERVENTIONS: Enhanced recovery pathways limited to preoperative, intraoperative, and postoperative management of pain, atrial fibrillation prevention, and nutrition optimization were implemented. MEASUREMENTS AND MAIN RESULTS: A total of 1,058 patients were included in this study. There were 374 patients in each pre- and post-ERP cohort after propensity matching, with no significant baseline differences between the 2 cohorts. Compared to the matched patients in the pre-ERP group, patients in the post-ERP group had decreased total ventilation hours (6.8 v 7.8, p = 0.006), less use of postoperative opioid analgesics as determined by total morphine milligram equivalent (32.5 v 47.5, p < 0.001), and a decreased rate of postoperative atrial fibrillation (23.3% v 30.5%, p = 0.032). Post-ERP patients also experienced less subjective pain and postoperative nausea and drowsiness as compared to their matched pre-ERP cohorts. CONCLUSIONS: Limited ERP implementation resulted in significantly improved perioperative outcomes. Patients additionally experienced less postoperative pain despite decreased opioid use. Implementation of ERP, even in a limited format, is a promising approach to improving outcomes in patients undergoing cardiac surgery.

A system approach to improving guideline-directed therapy for cardio-renal-metabolic conditions: The "beyond diabetes" initiative.

Objective: Despite demonstrating improvements in cardiovascular disease, kidney disease, and survival outcomes, guideline-directed antihyperglycemic medications such as sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like-peptide-1 receptor agonists (GLP1-RA), are underutilized. Many obstacles constrain their use including lack of systematic provider and patient education, concern for medication side effects, and patient affordability. Methods: We designed a multimodality, systems-based approach to address these challenges with the goal of increasing medication utilization across the largest healthcare system in New York State. This multispecialty collaborative included provider and patient education, an electronic health record-enabled platform to identify eligible patients, and access to pharmacists for medication guidance and addressing insurance coverage barriers. Surveys were administered following grand rounds lectures and knowledge-based questionnaires were given before and after case-based sessions for housestaff, with results analyzed using a two-sided Student's t-test. Rates of first prescriptions of SGLT2i/GLP1-RA in combined and individual analyses were compared between the pre- and post-education periods (6 months prior to 3/31/2021 and 6 months post 8/19/2021), and the change in prescriptions per 100 eligible-visits was assessed using the incidence density approach. Results: Among grand rounds participants, 69.3% of respondents said they would make changes to their clinical practice. Knowledge increased by 14.7% (p-value <0.001) among housestaff following case-based sessions. An increase in SGLT2i/GLP1-RA prescribing was noted for eligible patients among internal medicine, cardiology, nephrology, and endocrinology providers, from 11.9 per 100 eligible visits in the pre-education period to 14.8 in the post-education period (absolute increase 2.9 [24.4%], incidence risk ratio 1.24 [95% CI 1.18-1.31]; p-value <0.001). Increases in prescribing rates were also seen among individual medical specialties. Conclusions: Our "Beyond Diabetes" initiative showed an improvement in provider knowledge-base and was associated with a modest, but statistically significant increase in the use of SGLT2i and GLP1-RA throughout our healthcare system.

Identify potential allelochemicals from Humulus scandens (Lour.) Merr. root extracts that induce allelopathy on Alternanthera philoxeroides (Mart.) Griseb.

Although it is well-documented that invasion of invasive plants is promoted with allelopathic effects by inhibiting the growth and phenotypic performance of native plants, little is known conversely. In this study, the allelopathy effects of a native plant, Humulus scandens (Lour.) Merr., on a typical invasive species Alternanthera philoxeroides (Mart.) Griseb., was investigated by exposing A. philoxeroides seedlings to three chemical solvent extracts (i.e., petroleum ether extract (PE), ethyl acetate extract (EE), and n-butanol extract (NE) of H. scandens root (HR). The three chemical extracts inhibited the growth, stem length, node number, leaf number, leaf area, and root number, and increased malondialdehyde (MDA) content of A. philoxeroides seedlings, which indicated that the extracts inhibited the plant growth by damaging the membrane system of leaves. And the synthetical effect of allelopathy (SE) index indicated that EE had the greatest inhibition on the growth of A. philoxeroides. Fifty compounds were identified from the three extracts of HR using GC-MS analysis, among which 5 compounds (dibutyl phthalate, stigmasta-3,5-diene, 2,6-Di-tert-butylphenol campesterol, and neophytadiene) were identified from H. scandens root extracts for the first time. And n-hexadecanoic acid exists in all three extracts. The findings of the present study provide a novel method to potentially control the invasion of A. philoxeroides. However, field monitoring under natural conditions would be necessary to confirm in practice the results obtained with the bioassays.

Evaluating Asthma Mobile Apps to Improve Asthma Self-Management: User Ratings and Sentiment Analysis of Publicly Available Apps.

BACKGROUND: The development and use of mobile health (mHealth) apps for asthma management have risen dramatically over the past two decades. Asthma apps vary widely in their content and features; however, prior research has rarely examined preferences of users of publicly available apps. OBJECTIVE: The goals of this study were to provide a descriptive overview of asthma mobile apps that are publicly available and to assess the usability of asthma apps currently available on the market to identify content and features of apps associated with positive and negative user ratings. METHODS: Reviews were collected on June 23, 2020, and included publicly posted reviews until June 21, 2020. To characterize features associated with high or low app ratings, we first dichotomized the average user rating of the asthma app into 2 categories: a high average rating and a low average rating. Asthma apps with average ratings of 4 and above were categorized as having a high average rating. Asthma apps with average ratings of less than 4 were categorized as having a low average rating. For the sentiment analysis, we modeled both 2-word (bi-gram) and 3-word (tri-gram) phrases which commonly appeared across highly rated and lowly rated apps. RESULTS: Of the 10 apps that met the inclusion criteria, a total of 373 reviews were examined across all apps. Among apps reviewed, 53.4% (199/373) received high ratings (average ratings of 4 or 5) and 47.2% (176/373) received low ratings (average ratings of 3 or less). The number of ratings across all apps ranged from 188 (AsthmaMD) to 10 (My Asthma App); 30% (3/10) of apps were available on both Android and iOS. From the sentiment analysis, key features of asthma management that were common among highly rated apps included the tracking of peak flow readings (n=48), asthma symptom monitoring (n=11), and action plans (n=10). Key features related to functionality that were common among highly rated apps included ease of use (n=5). Users most commonly reported loss of data (n=14) and crashing of app (n=12) as functionality issues among poorly rated asthma apps. CONCLUSIONS: Our study results demonstrate that asthma app quality, maintenance, and updates vary widely across apps and platforms. These findings may call into question the long-term engagement with asthma apps, a crucial factor for determining their potential to improve asthma self-management and asthma clinical outcomes.

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It is an effective approach to control invasive plants based on the allelopathic effect of native plants with higher economic values, from the perspective of allelopathy. The aim of this study was to test the allelopathic effect of a local crop, sweet potato (Ipomoea batatas), on the invasive plant Alternanthera philoxeroides. Water extracts from different organs of sweet potato (roots, stems, leaves) with three concentrations (0.025, 0.05, 0.1 g·mL-1) were used in the study. To test the effect of sweet potato on rhizome growth of A. philoxeroides, the morphological index (ramet number, node number, leaf number, leaf area, plant height, total dry weight and root number of new ramets), allelopathic response index, trait values (succulent degree, root-shoot ratio, specific leaf area, leaf mass ratio, stem mass ratio, root mass ratio), CAT, POD, MDA and SOD in young leaves were measured. The results showed that 1) Water extracts from different organs of sweet potato with different concentrations differed in their effects on the growth of A. philoxeroides. Water extract from root with 0.1 g·mL-1 significantly inhibited all morphological indices. Except total dry weight and root number, other morphological indices decreased significantly with increasing concentration of water extract from all organs. 2) The synthetic allelopathic response index (RI) was negative under all treatments, indicating that water extract of sweet potato had negative effects on all indices of A. philoxeroides and thus inhibited their growth. Among all the treatments, water extract from root with a concentration of 0.1 g·mL-1 had the strongest allelopathic inhibition (RI=-0.73), followed by that from stem with a concentration of 0.1 g·mL-1(RI=-0.44) and from root with a concentration of 0.05 g·mL-1(RI=-0.44). 3) Water extract of sweet potato had significant inhibitory effects on the degree of succulence, root-shoot ratio, specific leaf area, and leaf mass ratio, but did not affect stem mass ratio and root mass ratio. 4) Water extract of sweet potato significantly increased the contents of MDA and SOD in the fresh leaves of A. philoxeroides, while had no effect on the contents of CAT and POD. All these results indicates that water extract of sweet potato significantly suppress the ramet growth of A. philoxeroides.

Effect of Coiling Temperature on Microstructure, Properties and Resistance to Fish-Scaling of Hot Rolled Enamel Steel.

The microstructure, mechanical properties, and hydrogen permeation behavior of hot rolled enamel steel were investigated. Three coiling temperatures were adopted to gain different sizes of ferrite grain and TiC precipitates. The results show that a large number of interphase precipitates of nano-sized TiC can be obtained at coiling temperatures of 650 and 700 °C, while a few precipitates are found in experimental steel when coiling temperature is 600 °C. The yield strength and ultimate tensile strength decrease with increasing coiling temperature, while elongation increases. The experimental steel has the best resistance to fish-scaling at coiling temperature of 700 °C, due to the large quantities of nano-sized interphase precipitates of TiC.