Heparin resistance management during cardiac surgery: a literature review and future directions.

INTRODUCTION: Heparin, a commonly used anticoagulant in cardiac surgery, binds to antithrombin III (ATIII) to prevent clot formation. However, heparin resistance (HR) can complicate surgical procedures, leading to increased thromboembolic risks and bleeding complications. Proper diagnosis and management of HR are essential for optimizing surgical outcomes. METHODOLOGY: Diagnosis of HR involves assessing activated clotting time (ACT) and HR assays. Management strategies were identified through a comprehensive review of the literature, including studies exploring heparin dosage adjustments, antithrombin supplementation, and alternative anticoagulants in cardiac surgery patients with HR. A thorough search of relevant studies on HR was conducted using multiple scholarly databases and relevant keywords, resulting in 59 studies that met the inclusion criteria. DISCUSSION: HR occurs when patients do not respond adequately to heparin therapy, requiring higher doses or alternative anticoagulants. Mechanisms of HR include AT III deficiency, PF4 interference, and accelerated heparin clearance. Diagnosis involves assessing ACT and HR assays. HR in cardiac surgery can lead to thromboembolic events, increased bleeding, prolonged hospital stays, and elevated healthcare costs. Management strategies include adjusting heparin dosage, supplementing antithrombin levels, and considering alternative anticoagulants. Multidisciplinary management of HR involves collaboration among various specialities. Strategies include additional heparin doses, fresh frozen plasma (FFP) administration, and antithrombin concentrate supplementation. Emerging alternatives to heparin, such as direct thrombin inhibitors and nafamostat mesilate, are also being explored. CONCLUSION: Optimizing the management of HR is crucial for improving surgical outcomes and reducing complications in cardiac surgery patients. Multidisciplinary approaches and emerging anticoagulation strategies hold promise for addressing this challenge effectively.

Photosynthetic light requirement near the theoretical minimum detected in Arctic microalgae.

Photosynthesis is one of the most important biological processes on Earth, providing the main source of bioavailable energy, carbon, and oxygen via the use of sunlight. Despite this importance, the minimum light level sustaining photosynthesis and net growth of primary producers in the global ocean is still unknown. Here, we present measurements from the MOSAiC field campaign in the central Arctic Ocean that reveal the resumption of photosynthetic growth and algal biomass buildup under the ice pack at a daily average irradiance of not more than 0.04 ± 0.02 µmol photons m-2 s-1 in late March. This is at least one order of magnitude lower than previous estimates (0.3-5 µmol photons m-2 s-1) and near the theoretical minimum light requirement of photosynthesis (0.01 µmol photons m-2 s-1). Our findings are based on measurements of the temporal development of the under-ice light field and concurrent measurements of both chlorophyll a concentrations and potential net primary production underneath the sea ice at 86 °N. Such low light requirements suggest that euphotic zones where photosynthesis can occur in the world's oceans may extend further in depth and time, with major implications for global productivity estimates.

The Profile and Characteristics of Young People Accessing Recently Implemented Community Forensic Child and Adolescent Mental Health Services (F:CAMHS) in Northern Ireland.

Children under the age of 18 who are known to forensic child and adolescent mental health services often present with complex psychosocial and behavioural needs that are elevated compared with those in the general youth population. The Forensic Child and Adolescent Mental Health Service for Northern Ireland (FCAMHSNI) was commissioned in 2014 to support these children. Despite almost a decade of implementation, the profile and characteristics in the service remain under-analysed, impeding service improvement and making international comparisons more difficult. The primary aim of the current study was to address the regional gaps in how the needs of those accessing FCAMHSNI are understood. A secondary aim was to capture comparable data. Data on 107 accepted referrals are included in the analyses. The majority of cases within this time period were male (81.1%, n = 86) and the majority of presenting behaviours were related to violence and aggression 62.3% (n = 48). However, some forms of violence, such as harmful sexual behaviour, was relatively low when compared with other jurisdictions. Specific demographic characteristics such as gender and religious background appeared to be significant risk factors for referral to the service. Almost all of the sample are known to have experienced at least one potentially traumatic event (95.2%) and in more than one-third of cases, service users presented with co-morbid issues (35.6%, n = 37). These observations are discussed. This study adds to the growing international literature around the needs of forensically involved youth and helps to inform future service development and provision.

Curving expectations: The minimal impact of structural curvature in biological puncture mechanics.

Living organisms have evolved various biological puncture tools, such as fangs, stingers, and claws, for prey capture, defense, and other critical biological functions. These tools exhibit diverse morphologies, including a wide range of structural curvatures, from straight cactus spines to crescent-shaped talons found in raptors. While the influence of such curvature on the strength of the tool has been explored, its biomechanical role in puncture performance remains untested. Here, we investigate the effect of curvature on puncture mechanics by integrating experiments with finite element simulations. Our findings reveal that within a wide biologically relevant range, structural curvature has a minimal impact on key metrics of damage initiation or the energies required for deep penetration in isotropic and homogeneous target materials. This unexpected result improves our understanding of the biomechanical pressures driving the morphological diversity of curved puncture tools and provides fundamental insights into the crucial roles of curvature in the biomechanical functions of living puncture systems.

Functional Outcome after Direct Anterior Approach Total Hip Arthroplasty (DAA-THA) for Coxa Profunda and Protrusio Acetabuli-A Retrospective Study.

Objective: The direct anterior approach (DAA) is a recognized technique for total hip arthroplasty (THA) that spares soft tissue. Functional and clinical outcomes following THA via the DAA in patients with complex acetabular deformities, specifically coxa profunda (CP) and protrusio acetabuli (PA), have yet to be determined. Methods: A retrospective analysis was conducted on 188 primary THA cases, including 100 CP hips and 88 PA hips, performed via the DAA. Functional and clinical outcomes were evaluated by means of the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Harris Hip Score (HHS) preoperatively and at a mean follow-up of 46 ± 14 months. Furthermore, potential complications were assessed. Results: From the preoperative to the latest postoperative visit, a significant improvement in the WOMAC total score was observed (CP: -34.89 ± 20.66; PA: -40.38 ± 21.11). The length of stay (LOS) was the only parameter predictive of the postoperative WOMAC total score, with each day of LOS increasing the postoperative WOMAC by a mean of 1.77 points (p < 0.01). The HHS improved by 38.37 ± 14.23 (PA-group) and 32.79 ± 14.89 points (CP-group). No significant difference in the patient-reported outcome measures (PROMs) between the CP- and PA-group was found. The survival rate for any revision was 97.70% (PA-group) and 92.80% (CP-group). Conclusion: The results of this study indicate that the minimally invasive DAA was not predictive of the functional and clinical outcome following DAA-THA in patients with CP and PA. Improvements in the mean WOMAC and HHS scores were above or within the reported MCID. Additionally, revision rates were well below those reported in the literature for short and intermediate follow-up periods.

Quality vs. Quantity: The Consequences of Elevated CO2 on Wood Biomaterial Properties.

Since the late 1800s, anthropogenic activities such as fossil fuel consumption and deforestation have driven up the concentration of atmospheric CO2 around the globe by >45%. Such heightened concentrations of carbon dioxide in the atmosphere are a leading contributor to global climate change, with estimates of a 2-5° increase in global air temperature by the end of the century. While such climatic changes are mostly considered detrimental, a great deal of experimental work has shown that increased atmospheric CO2 will actually increase growth in various plants, which may lead to increased biomass for potential harvesting or CO2 sequestration. However, it is not clear whether this increase in growth or biomass will be beneficial to the plants, as such increases may lead to weaker plant materials. In this review, I examine our current understanding of how elevated atmospheric CO2 caused by anthropogenic effects may influence plant material properties, focusing on potential effects on wood. For the first part of the review, I explore how aspects of wood anatomy and structure influence resistance to bending and breakage. This information is then used to review how changes in CO2 levels may later these aspects of wood anatomy and structure in ways that have mechanical consequences. The major pattern that emerges is that the consequences of elevated CO2 on wood properties are highly dependent on species and environment, with different tree species showing contradictory responses to atmospheric changes. In the end, I describe a couple avenues for future research into better understanding the influence of atmospheric CO2 levels on plant biomaterial mechanics.

Vitamin D Deficiency Is Frequent in Patients with Rapidly Destructive Osteoarthritis-Data from a Single-Center Analysis.

BACKGROUND: Rapidly destructive osteoarthritis (RDO) of the hip joint is characterised by the rapid destruction of the femoral head with or without acetabular involvement. There has been increasing interest in this disease over the past years; however, the entity is still poorly understood, and its pathophysiology remains unknown. Yet, there is ample evidence today that increased bone metabolism might play a role in the onset and progression of the disease. Vitamin D is of utmost importance to maintain a balanced bone metabolism. However, whether vitamin D deficiency is involved in disease development remains to be elucidated. Further, the vitamin D status of patients with RDO has not yet been analysed. For this reason, the objective of this study was to assess the vitamin D status of patients with RDO. Moreover, the aim was to clarify whether there is a difference in the vitamin D status of patients with RDO compared with patients with primary osteoarthritis (OA). METHODS: In this single-centre analysis, the 25(OH)D, PTH, and calcium levels of 29 patients who presented with RDO between 2020 and 2022 were assessed. RESULTS: Altogether, 97% of patients (28/29) were vitamin D deficient, a further 3% (1/29) were vitamin D insufficient, and not a single patient presented with a sufficient vitamin D status. Notably, the vitamin D levels of RDO patients (mean = 11.04 ng/mL) were significantly lower than the vitamin D levels of patients with OA (mean = 22.16 ng/mL, p = 0.001). CONCLUSION: In conclusion, we found a widespread and high rate of vitamin D deficiency in patients with RDO. Hence, we believe that 25(OH)D status should routinely be analysed in these patients.

Living with Dysphagia: A Survey Exploring the Experiences of Adults Living with Neuromuscular Disease and their Caregivers in the United Kingdom.

Background: Dysphagia is common in adults living with neuromuscular disease (NMD). Increased life expectancy, secondary to improvements in standards of care, requires the recognition and treatment of dysphagia with an increased priority. Evidence to support the establishment of healthcare pathways is, however, lacking. The experiences of people living with NMD (pplwNMD) and their caregivers are valuable to guide targeted, value-based healthcare. Objective: To generate preliminary considerations for neuromuscular dysphagia care and future research in the United Kingdom, based on the experiences of those living with, or caring for, people with NMD. Methods: Two surveys (one for adults living with NMD and dysphagia, and a second for caregivers) were co-designed with an advisory group of people living with NMD. Surveys were electronically distributed to adults living with NMD and their caregivers between 18th May and 26th July 2020. Distribution was through UK disease registries, charity websites, newsletters, and social media. Results: Adults living with NMD receive little information or education that they are likely to develop swallowing difficulties. Most respondents report wanting this information prior to developing these difficulties. Difficulties with swallowing food and medication are common in this group, and instrumental assessment is considered a helpful assessment tool. Both adults living with NMD and caregivers want earlier access to neuromuscular swallowing specialists and training in how best to manage their difficulties. Conclusions: Improvement is needed in the dysphagia healthcare pathway for adults living with NMD to help mitigate any profound physical and psychological consequences that may be caused by dysphagia. Education about swallowing difficulties and early referral to a neuromuscular swallowing specialist are important to pplwNMD and their caregivers. Further research is required to better understand the experiences of pplwNMD and their caregivers to inform the development of dysphagia healthcare pathways.

Zirconium as a Promising Synovial Biomarker for Loose Cemented Knee Prosthesis.

BACKGROUND: Aseptic loosening is the most common mode of failure after total knee arthroplasty. Despite this, the diagnosis often remains challenging and mainly relies on imaging modalities. Until today, no biomarker exists to aid in diagnosing loosening of the implants. As zirconium (Zr) is often found in bone cement, where it serves as radiopacifier, this study aimed to establish Zr as a synovial biomarker for loosened cemented knee prostheses. METHODS: A total of 31 patients scheduled for revision of a cemented knee prostheses were included. In all patients, the initial used cement contained Zr. After arthrotomy, specimens of synovial fluid were taken and levels of Zr were measured by inductively coupled plasma mass spectrometry. Depending on the necessary amount of force for explantation, the implants were graded "loose" or "well-fixed". Preoperative radiographs were evaluated by 2 independent physicians. RESULTS: The concentration of Zr in the synovial fluid differed significantly (P < .001) between the "loose" (mean 170.9 µg/L, range 0 to 1941 µg/L) and the "well-fixed" (mean 0.6 µg/L, range 0 to 6 µg/L) implants. The receiver operating characteristic analysis revealed 0.25 µg/l as an optimal cutoff value leading to a sensitivity of 0.84, a specificity of 0.92, a positive predictive value of 0.94, and a negative predictive value of 0.79. There was no significant difference in the diagnostic performance compared to radiographs (P = .66). CONCLUSIONS: Zirconium proved to be a reliable novel synovial biomarker for diagnosing aseptic loosening of knee prothesis fixed with cement containing Zr. This biomarker should not be interpreted in isolation, but in combination with existing diagnostic tools.

Does Body Mass Index (BMI) Affect the Reconstruction of Biomechanical Parameters in Patients Undergoing Total Hip Replacement (THR) through the Direct Anterior Approach (DAA)?

OBJECTIVE: Direct anterior approach total hip replacement (DAA-THR) is gaining increased interest due to its tissue-sparing nature and rapid recovery. Obesity has been shown to be a significant parameter influencing cup positioning in DAA-THR. It was the intention of this retrospective study to examine how obesity would influence the restoration of native hip biomechanical parameters during DAA-THR. MATERIALS AND METHODS: A total of 74 patients from a high-volume university orthopedic center after unilateral DAA-THA were included. Patients were retrospectively allocated to a study group (BMI > 30 kg/m2) and a control group (BMI < 30 kg/m2). Furthermore, propensity-score matching for baseline parameters was performed, leaving 30 patients in each group. Biomechanical parameters of the hip (i.e., femoral offset (FO), abductor lever arm (ABL), acetabular offset (AO), center of rotation (COR), stem alignment (SA), body weight lever arm (BWL), cup inclination (CI), and leg length discrepancy (LLD) were evaluated on standardized plain radiographs, and parameters were compared to the native contralateral hip. RESULTS: Mean BMI in the study group was 35.07 ± 5.13 kg/m2 and 25.43 ± 2.64 kg/m2 in the control group. There was a significant decrease of the ABL only in the study cohort (p = 0.01). CI and SA did not differ between both cohorts. FO was slightly increased compared to the native hip in both groups. There was a marginally higher but non-significant proportion of improper FO restoration in the study group (19 vs. 16 patients, p = 0.60). CONCLUSIONS: Obesity, as quantified by BMI, only has a limited impact on the adequate reconstruction of native biomechanical parameters of the hip during DAA-THR. ABL was the only parameter to be significantly decreased in the overweight patients after DAA-THR. Therefore, special care should be taken on proper acetabular reaming and consequent seating of the cup in the obese patient to avoid excessive lateral positioning.

Epichloë fungal endophyte interactions in perennial ryegrass (Lolium perenne L.) modified to accumulate foliar lipids for increased energy density.

BACKGROUND: Commercial cultivars of perennial ryegrass infected with selected Epichloë fungal endophytes are highly desirable in certain pastures as the resulting mutualistic association has the capacity to confer agronomic benefits (such as invertebrate pest deterrence) largely due to fungal produced secondary metabolites (e.g., alkaloids). In this study, we investigated T2 segregating populations derived from two independent transformation events expressing diacylglycerol acyltransferase (DGAT) and cysteine oleosin (CO) genes designed to increase foliar lipid and biomass accumulation. These populations were either infected with Epichloë festucae var. lolii strain AR1 or Epichloë sp. LpTG-3 strain AR37 to examine relationships between the introduced trait and the endophytic association. Here we report on experiments designed to investigate if expression of the DGAT + CO trait in foliar tissues of perennial ryegrass could negatively impact the grass-endophyte association and vice versa. Both endophyte and plant characters were measured under controlled environment and field conditions. RESULTS: Expected relative increases in total fatty acids of 17-58% accrued as a result of DGAT + CO expression with no significant difference between the endophyte-infected and non-infected progeny. Hyphal growth in association with DGAT + CO expression appeared normal when compared to control plants in a growth chamber. There was no significant difference in mycelial biomass for both strains AR1 and AR37, however, Epichloë-derived alkaloid concentrations were significantly lower on some occasions in the DGAT + CO plants compared to the corresponding null-segregant progenies, although these remained within the reported range for bioactivity. CONCLUSIONS: These results suggest that the mutualistic association formed between perennial ryegrass and selected Epichloë strains does not influence expression of the host DGAT + CO technology, but that endophyte performance may be reduced under some circumstances. Further investigation will now be required to determine the preferred genetic backgrounds for introgression of the DGAT + CO trait in combination with selected endophyte strains, as grass host genetics is a major determinant to the success of the grass-endophyte association in this species.

Development and calibration of a high dynamic range and autonomous ocean-light instrument to measure sub-surface profiles in ice-covered waters.

The optical chain and logger (OptiCAL) is an autonomous ice-tethered observatory equipped with multiple light sensors for mapping the variation of light with depth. We describe the instrument and present an ensemble calibration for downwelling irradiance E P A R in [µm o l m -2 s -1]. Results from a long-term deployment in the Arctic Ocean demonstrate that the OptiCAL can cover the high dynamic range of under-ice light levels from July to November and produce realistic values in terms of magnitude when compared to modeled surface irradiance. Transient features of raised light levels at specific depths associated with nearby leads in the ice underline the importance of depth-resolved light measurements.

Accuracy of Positioning and Risk Factors for Malpositioning Custom-Made Femoral Stems in Total Hip Arthroplasty-A Retrospective Multicenter Analysis.

Total hip arthroplasty (THA) is commonly performed using off-the-shelf implants. In the case of a severe mismatch between the anatomy of the proximal femur and the geometry of the stem, the use of custom-made stems might become necessary. The goal of this study was to investigate the precision of the implantation of custom-made stems of one manufacturer (CTX stem, AQ Implants) and to determine risk factors for malpositioning. All patients receiving a custom-made CTX stem between 2014 and 2020 at six high-volume academic centers were retrospectively recruited. The achieved position of the stem, as determined by stem version, stem coronal angle, and implantation depth on radiographs, was compared to the plan. The influence of radiographic and demographic parameters on the position was investigated. The results revealed a high variability of the achieved implant position in relation to the preoperative plan. While the stem coronal angle only differed slightly from the intended position, the stem version and the implantation depth showed a high frequency and amount of deviation. Right stems showed significantly higher positions than planned. Surgeons must be aware of this potential problem when implanting custom-made stems.

The AMADEUS score is not a sufficient predictor for functional outcome after autologous chondrocyte implantation (ACI) of the knee: data from the German Cartilage Registry (KnorpelRegister DGOU).

INTRODUCTION: The AMADEUS (Area Measurement And DEpth and Underlying Structures) score has advanced to a commonly used tool for MRI-based chondral defect severity grading prior to cartilage knee surgery. It was the intention of this study to assess the AMADEUS for a potential correlation with clinical data by patient-reported outcome measures (PROMs). METHODS: A total of 51 patients undergoing ACI (autologous chondrocyte implantation) between 2016 and 2022 were found eligible and retrospectively analyzed. All patients were registered in the German Cartilage Registry prior to surgery and follow-up data were collected using the Knee Osteoarthritis Outcome score (KOOS), the International Knee Documentation Committee (IKDC) Form and the numeric rating scale (NRS). Pre-operative MRI images were scored by three raters using the AMADEUS classification system, and an overall AMADEUS score was calculated which was subsequently correlated with pre- and post-operative PROMs. RESULTS: Mean patient age was 32.67 ± 8.37 years and mean defect size area 343.04 mm2 ± 139.45 mm2. No correlative capacity of the pre- and postoperative IKDC, KOOS or NRS scores was found with the AMADEUS final score or any of its subscores. From the pre- to postoperative visit, a significant improvement of the PROMs (IKDC: 45.53 ± 21.00 vs. 59.83 ± 17.93, p = 0.04; KOOS Pain: 58.00 ± 16.70 vs. 76.06 ± 19.20, p = 0.03; KOOS ADL: 64.17 ± 18.76 vs. 82.11 ± 16.68, p < 0.01; KOOS Sports: 26.11 ± 18.52 vs. 50.56 ± 23.94, p = 0.01; KOOS QOL: 25.50 ± 14.26 ± 45.28 ± 19.03, p = 0.00) was found. Intraclass correlation coefficients showed an overall good interrater agreement for the AMADEUS total score (ICC = 0.75). CONCLUSIONS: Study results suggest no correlative capacity of the AMADEUS with routinely used PROMs in patients undergoing ACI. Therefore, radiographically assessed cartilage defect characteristics poorly translate to pre- and postoperative patient-reported outcome data.

How venom pore placement may influence puncture performance in snake fangs.

When designing experimental studies, it is important to understand the biological context of the question being asked. For example, many biological puncture experiments embed the puncture tool to a standardized depth based on a percentage of the total tool length, to compare the performance between tools. However, this may not always be biologically relevant to the question being asked. To understand how definitions of penetration depth may influence comparative results, we performed puncture experiments on a series of venomous snake fangs using the venom pore location as a functionally relevant depth standard. After exploring variation in pore placement across snake phylogeny, we compared the work expended during puncture experiments across a set of snake fangs using various depth standards: puncture initiation, penetration to a series of depths defined by the venom pore and penetration to 15% of fang length. Contrary to our hypothesis, we found almost no pattern in pore placement between clades, dietary groups or venom toxicity. Rank correlation statistics of our experimental energetics results showed no difference in the broad comparison of fangs when different puncture depth standards were used. However, pairwise comparisons between fangs showed major shifts in significance patterns between the different depth standards used. These results imply that the interpretation of experimental puncture data will heavily depend upon which depth standard is used during the experiments. Our results illustrate the importance of understanding the biological context of the question being addressed when designing comparative experiments.

Morphological variation in the vomer of aquatic and terrestrial spelerpini salamanders.

The vomer is an important tooth-bearing cranial bone in the lungless salamanders (Caudata: Plethodontidae) that serves different functional roles in aquatic versus terrestrial feeding. Vomerine tooth rows that run parallel with the maxillary teeth are thought to help grasp prey while expelling water from the mouth, while posterior extensions of the tooth row may help terrestrial taxa bring prey down the throat. We hypothesize that these two general morphological types will correlate with the habitat (aquatic vs. terrestrial) of adult salamanders. Alternatively, variation in form may be due to taxonomic effects, such that closely related species will have similar vomer morphology regardless of adult habitat. To test this hypothesis, we examined vomer shape on a set of species of the morphologically diverse tribe Spelerpini, in which two of the five genera (Eurycea and Gyrinophilus) include both aquatic and terrestrial species. Data were collected using micro computed tomography (micro-CT) scans from specimens from the Field Museum of Natural History and the Illinois Natural History Survey; additional data was obtained from public online repositories including Morphosource.org. Two-dimensional geometric morphometric analyses were performed to capture shape variation of both the vomer and the vomerine tooth row. We found clear separation between aquatic and terrestrial taxa, with most of the variation due to differences in the vomerine tooth row. Differences ascribed to habitat use likely correspond to feeding behavior, and the functional role of the vomer in prey processing warrants further investigation in this species-rich salamander family.