Long-Term Mortality Risk According to Cardiorespiratory Fitness in Patients Undergoing Coronary Artery Bypass Graft Surgery.

The aim of this study was to evaluate the association between cardiorespiratory fitness (CRF) and long-term survival in United States (US) Veterans undergoing CABG. We identified 14,550 US Veterans who underwent CABG at least six months after completing a symptom-limited exercise treadmill test (ETT) with no evidence of cardiovascular disease. During a mean follow-up period of 10.0 ± 5.4 years, 6502 (43.0%) died. To assess the association between CRF and risk of mortality, we formed the following five fitness categories based on peak workload achieved (metabolic equivalents or METs) prior to CABG: Least-Fit (4.3 ± 1.0 METs (n = 4722)), Low-Fit (6.8 ± 0.9 METs (n = 3788)), Moderate-Fit (8.3 ± 1.1 METs (n = 2608)), Fit (10.2 ± 0.8 METs (n = 2613)), and High-Fit (13.0 ± 1.5 METs (n = 819)). Cox proportional hazard models were used to calculate risk across CRF categories. The models were adjusted for age, body mass index, race, cardiovascular disease, percutaneous coronary intervention prior to ETT, cardiovascular medications, and cardiovascular disease risk factors. P-values < 0.05 using two-sided tests were considered statistically significant. The association between cardiorespiratory fitness and mortality was inverse and graded. For every 1-MET increase in exercise capacity, the mortality risk was 11% lower (HR = 0.89; CI: 0.88-0.90; p < 0.001). When compared to the Least-Fit category (referent), mortality risk was 22% lower in Low-Fit individuals (HR = 0.78; CI: 0.73-0.82; p < 0.001), 31% lower in Moderate-Fit individuals (HR = 0.69; CI: 0.64-0.74; p < 0.001), 52% lower in Fit individuals (HR = 0.48; CI: 0.44-0.52; p < 0.001), and 66% lower in High-Fit individuals (HR = 0.34; CI: 0.29-0.40; p < 0.001). Cardiorespiratory fitness is inversely and independently associated with long-term mortality after CABG in Veterans referred for exercise testing.

Effects of Concomitant CABG on Outcomes in Veterans Who Require Surgery for Endocarditis.

BACKGROUND: Infective Endocarditis (IE) is a complicated disease frequently accompanied by coronary artery disease (CAD) though no clear guidelines exist for when concomitant revascularization should be undertaken once valve surgery is indicated. Data on this topic within the United States (US) Veteran population, who have unique healthcare needs when compared to the civilian population, is sparse. We investigated the impact of concomitant coronary artery bypass grafting (CABG) on morbidity and mortality in US Veterans requiring surgical management of IE. METHODS: We identified 489 patients who underwent surgical management of IE between January 1 2010 and December 31 2020 at any of 43 Veterans Affairs (VA) cardiac surgery centers in the US. Patients were stratified based on who underwent concomitant CABG at the time of operation. Primary outcomes included the occurrence of postoperative myocardial infarction (MI), stroke, or mortality. Continuous variables were compared using independent t-tests or Mann Whitney U tests, and categorical variables were compared using the Chi square test. Cox proportional-hazard models were used to calculate risk for primary outcomes based on group. RESULTS: 61 patients (12.5%) underwent concomitant CABG for CAD. After adjusting for significant covariates, patients who underwent CABG had a higher long-term risk of MI (adjusted hazard ratios (aHR) 2.37, 95% CI: 1.29-4.35, p = 0.005) and higher risk of MI at 30-days (aHR 2.34, 95% CI: 1.06-5.19, p = 0.035). Concomitant CABG was not associated with long-term stroke or death, 30-day stroke or death, or perioperative complications. On sub-analysis of patients with moderate to severe CAD, rates of MI were higher in the CABG group at 30 days (25.9 vs. 3.4%, p = 0.016) and 1 year (33.3 vs. 3.4%, p = 0.004), though not long-term. The mean number of grafts was 1.51 ± 0.76, with only one graft performed in 65.6% (40/61) of patients. CONCLUSIONS: Concomitant CABG at the time of operation for IE was associated with increased risk of MI at 30-day and long-term, though most CABGs involved a low number of grafts. It was not associated with 30-day stroke or death, long term stroke or death, or perioperative complications. The optimal treatment of CAD noted during preoperative evaluation for veterans undergoing surgery for IE remains unclear.

Predictors of 30-Day Pulmonary Complications after Video-Assisted Thoracoscopic Surgery Lobectomy.

BACKGROUND: Pulmonary complications are the most common adverse event after lung resection, yet few large-scale studies have examined pertinent risk factors after video-assisted thoracoscopic surgery (VATS) lobectomy. Veterans, older and less healthy compared with nonveterans, represent a cohort that requires further investigation. Our objective is to determine predictors of pulmonary complications after VATS lobectomy in veterans. METHODS: A retrospective review was conducted on patients who underwent VATS lobectomy from 2008 to 2018 using the Veterans Affairs Surgical Quality Improvement Program database. Patients were divided into two cohorts based on development of a pulmonary complication within 30 days. Patient characteristics were compared via multivariable analysis to determine clinical predictors associated with pulmonary complication and reported as adjusted odds ratios (aORs) with 95% confidence intervals. Patients with preoperative pneumonia, ventilator dependence, and emergent cases were excluded. RESULTS: In 4,216 VATS lobectomy cases, 480 (11.3%) cases had ≥1 pulmonary complication. Preoperative factors independently associated with pulmonary complication included chronic obstructive pulmonary disease (COPD) (aOR = 1.37 [1.12-1.69]; p = 0.003), hyponatremia (aOR = 1.50 [1.06-2.11]; p = 0.021), and dyspnea (aOR = 1.33 [1.06-1.66]; p = 0.013). Unhealthy alcohol consumption was associated with pulmonary complication via univariable analysis (17.1 vs. 13.0%; p = 0.016). Cases with pulmonary complication were associated with increased mortality (12.1 vs. 0.8%; p < 0.001) and longer length of stay (12.0 vs. 6.8 days; p < 0.001). CONCLUSION: This analysis revealed several preoperative factors associated with development of pulmonary complications. It is imperative to optimize pulmonary-specific comorbidities such as COPD or dyspnea prior to VATS lobectomy. However, unhealthy alcohol consumption and hyponatremia were linked with development of pulmonary complication in our analysis and should be addressed prior to VATS lobectomy. Future studies should explore long-term consequences of pulmonary complications.

Microbiology of Infective Endocarditis in United States Veterans - Association Between Causative Organism and Short- and Long-Term Outcomes.

BACKGROUND: Previous studies have elucidated the relationship between causative organism and outcomes in infective endocarditis, however this relationship has not been studies in United States Veterans. The aim of this manuscript is to evaluate the association between causative organism and short-term and long-term outcomes in United States (US) Veterans with infective endocarditis (IE) requiring surgical management between 2010-2020. METHODS: We analyzed 489 patients with surgically treated IE from the Veterans Affairs (VA) Surgical Quality Improvement Program and the VA Informatics and Computing Infrastructure databases. Patients were divided into groups using causative organism identified from blood or intraoperative cultures - Staphylococcus, Streptococcus, Gram-negative rods, Enterococcus, Polymicrobial, and Unknown/Culture Negative. Other identified organisms were excluded from analysis. Cox proportional hazard models were used to calculate risk for stroke/transient ischemic attack (TIA), myocardial infarction (MI), and death based on group. The models were adjusted for covariates using backward elimination. Continuous variables were compared using ANOVA or Kruskal-Wallis H tests, and categorical variables were compared using Chi square tests. RESULTS: Mean follow-up was 4.0 ± 6.3 years. Gram negative rods (GNRs) were associated with greater risk of long-term mortality (adjusted hazard ratios (aHR) 2.15, 95% CI: 1.20-3.86, p = 0.01). Enterococcus was associated with long-term risk of MI (aHR 2.05, 95% CI: 1.07-3.94, p = 0.03). Resistant organisms, such as methicillin-resistant staphylococcus aureus, were associated with long-term risk of MI (aHR 2.51, 95% CI: 1.14-5.45, p = 0.02). Polymicrobial infections were associated with greater risk of perioperative complications, including prolonged mechanical ventilation (48 hrs) (aHR 1.76, 95% CI: 1.05-2.97, p = 0.034), tracheostomy (aHR 5.64, 95% CI: 2.35-13.55, p < 0.001), and prolonged ICU stay (5 days) (aHR 1.39, 95% CI: 1.01-1.91, p = 0.043). CONCLUSIONS: In US Veterans, polymicrobial infections had notably worse perioperative outcomes but similar long-term outcomes in comparison to monomicrobial infections. GNR infections were associated with increased long-term mortality. Enterococcus and resistant organisms were associated with increased long-term risk of MI. Polymicrobial infections were associated with greater risk of perioperative complications, including prolonged mechanical ventilation, tracheostomy, and prolonged ICU stay.

Factors influencing performance and injury risk in elite female Gaelic team sport players and future research directions: a narrative review.

BACKGROUND: Sports science research in elite female Gaelic team sports has increased in recent years, but still a large disparity exists between the volume of studies involving male and female players. As a consequence of this, it is difficult for practitioners to develop an evidence-based approach when working with female players. MAIN BODY: In this review, we discuss the current research available in elite female Gaelic team sports with focus on seven specific areas including physical and physiological demands, anthropometric and performance characteristics, injury risk, nutritional considerations, and female physiology. There appears to be unique physical demands data in match play across positions in Camogie, however, there is currently no comparative data available in ladies Gaelic football. Similarly, there is no research available on the physiological demands of both elite female Gaelic team sports. According to existing literature, performance characteristics such as speed and power are lower in this population compared to other elite female team sports. Although data is limited, the anthropometric characteristics of elite female Gaelic team sport players appear homogenous with some positional differences observed at a sub-elite level. Previous research has demonstrated a high prevalence of lower limb injuries in female elite Gaelic team sports and the provision of quality, evidence-based strength & conditioning could help mitigate these injury risks. Female Gaelic team sport players have been shown to have poor nutrition knowledge and inadequate intakes of micronutrients. Finally, although menstrual cycle phase and oral contraceptives have been shown to influence performance in other female intermittent sports, to date there has not been any research carried out in elite female Gaelic team sport players. CONCLUSIONS: It is evident that limited research has been carried out on elite female Gaelic sport players. More up-to-date, high-quality investigations are needed to address the research gaps, which in turn should enable practitioners in the field to apply sound, evidence-based practice/theory when working with this population.

Epidemiology of Coronary Artery Disease.

Although the mortality of coronary artery disease (CAD) has declined over recent decades, CAD remains the leading cause of death in the United States (US) and presents a significant economic burden. Epidemiologic studies have identified numerous risk factors for CAD. Some risk factors-including smoking, hypertension, dyslipidemia, and physical inactivity-are decreasing within the US population while Others, including advanced age, diabetes, and obesity are increasing. The most significant historic advances in CAD therapy were the development of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and lipid-lowering medications. Contemporary management of CAD includes primary and secondary prevention via medical management and revascularization when appropriate based on best available evidence. Despite the increasing prevalence of CAD nationwide, there has been a steady decline in the number of CABGs and PCIs performed in the US for the past decade. Patients with CABG are becoming older and with more comorbid conditions, although mortality associated with CABG has remained steady.

Epidemiology of Valvular Heart Disease.

Acquired diseases of the aortic and mitral valves are the most common cause of morbidity and mortality among Valvular heart diseases. Aortic stenosis (AS) is increasing in incidence in the United States (4,43 US), driven largely by an aging demographic. Aortic valve replacement is the only effective treatment of AS and has a dramatic mortality benefit. Mitral valve regurgitation (MR) is the most common form of valvular heart disease (VHD) in the US, whereby MR is most often the result of mitral valve prolapse; rheumatic heart disease (RHD) is a more common etiology of MR in underdeveloped countries. interventions for MR in the US are increasing.

Training Load Monitoring Considerations for Female Gaelic Team Sports: From Theory to Practice.

Athlete monitoring enables sports science practitioners to collect information to determine how athletes respond to training loads (TL) and the demands of competition. To date, recommendations for females are often adapted from their male counterparts. There is currently limited information available on TL monitoring in female Gaelic team sports in Ireland. The collection and analysis of female athlete monitoring data can provide valuable information to support the development of female team sports. Athletic monitoring can also support practitioners to help minimize risk of excessive TL and optimize potential athletic performance. The aims of this narrative review are to provide: (i) an overview of TL athlete monitoring in female team sports, (ii) a discussion of the potential metrics and tools used to monitor external TL and internal TL, (iii) the advantages and disadvantages of TL modalities for use in Gaelic team sports, and (iv) practical considerations on how to monitor TL to aid in the determination of meaningful change with female Gaelic team sports athletes.

Correcting a rare Congenital Coronary Anomaly in an Adult-A Case Report.

Anomalous origin of the right coronary artery from the pulmonary artery is an extremely rare condition with an uncertain natural history. Here, we present an otherwise healthy active duty service member who was found to have anomalous right coronary artery arising from the pulmonary artery as an incidental discovery during a workup for possible pulmonary embolus. We describe a preoperative workup which showed dilation of the coronaries and evidence of ischemia. Operative technique for restoration of a two-vessel coronary system is described. Postoperative imaging demonstrated reduction in the coronary dilation and resolution of ischemia.

Bridging burn care education with modern technology, an integration with high fidelity human patient simulation.

OBJECTIVE: The Advanced Burn Life Support (ABLS) program is a burn-education curriculum nearly 30 years in the making, focusing on the unique challenges of the first 24h of care after burn injury. Our team applied high fidelity human patient simulation (HFHPS) to the established ABLS curriculum. Our hypothesis was that HFHPS would be a feasible, easily replicable, and valuable adjunct to the current curriculum that would enhance learner experience. METHODS: This prospective, evidenced-based practice project was conducted in a single simulation center employing the American Burn Association's ABLS curriculum using HFHPS. Participants managed 7 separate simulated polytrauma and burn scenarios with resultant clinical complications. After training, participants completed written and practical examinations as well as satisfaction surveys. RESULTS: From 2012 to 2013, 71 students participated in this training. Simulation (ABLS-Sim) participants demonstrated a 2.5% increase in written post-test scores compared to traditional ABLS Provider Course (ABLS Live) (p=0.0016). There was no difference in the practical examination when comparing ABLS-Sim versus ABLS Live. Subjectively, 60 (85%) participants completed surveys. The Educational Practice Questionnaire showed best practices rating of 4.5±0.7; with importance of learning rated at 4.4±0.8. The Simulation Design Scale rating for design was 4.6±0.6 with an importance rating of 4.4±0.8. Overall Satisfaction and Self-Confidence with Learning were 4.4±0.7 and 4.5±0.7, respectfully. CONCLUSIONS: Integrating HFHPS with the current ABLS curriculum led to higher written exam scores, high levels of confidence, satisfaction, and active learning, and presented an evidenced-based model for education that is easily employable for other facilities nationwide.

Femoral artery rupture during total hip arthroplasty.

Vascular injuries are an uncommon but significant complication of total hip arthroplasty. We present a case of femoral artery rupture through an atherosclerotic plaque during primary total hip arthroplasty and a review of the published literature. The early recognition and prompt treatment of this complication can reduce the mortality and morbidity associated with this injury.

Alcoholic liver disease - assessment and management.

BACKGROUND: Alcohol is a major cause of liver disease in Australia and the incidence of end stage liver disease among young adult Australians is rising. OBJECTIVE: This article explores the types of alcoholic liver disease, their pathogenesis and detection, and the investigation and management of these conditions. DISCUSSION: Alcoholic liver disease is often silent until complications develop; therefore clinicians need a high index of suspicion to detect individuals with heavy alcohol consumption and evolving liver disease. At a population level, strategies to reduce per capita alcohol consumption can be expected to reduce mortality from alcohol related disease. At an individual level, early diagnosis, abstinence and effective treatment of complications are pivotal to reducing mortality. The cornerstone of management of chronic alcoholic liver disease is abstinence from alcohol and good nutrition. Other important aspects of management include care when prescribing medications, immunisations and early referral for complications.

The impact of ulnar collateral ligament tear and reconstruction on contact pressures in the lateral compartment of the elbow.

HYPOTHESIS: Complete ulnar collateral ligament (UCL) injury increases articular pressure and reduces contact area compared with the normal intact UCL. UCL reconstruction restores the contact area and contact pressure observed in the native joint. MATERIALS AND METHODS: Six male cadaveric elbows were mounted on a custom jig capable of simulating the 2 critical phases of the throwing motion during pitching. A contact sensor was placed through an anterior arthrotomy into the radiocapitellar joint. Each specimen then underwent valgus loading at 1.75 and 5.25 Nm of torque with the biceps, brachialis, and triceps under axial load in each testing condition. RESULTS: The average valgus laxity in the intact elbow at 90° was 3.7° ± 0.6° at the 5.25 Nm level of torque, which doubled after transection. The reconstruction group demonstrated less laxity (2.4° ± 0.4°) and reduced valgus angulation of the ulna at 5.25 Nm of torque. The transected UCL condition showed peak contact pressure 67% higher compared with the native ligament group at 5.25 Nm of torque. The reconstructed group increased peak articular cartilage pressures by 33% from the native ligament. At 5.25 Nm of torque for the 90° flexion phase, the transected UCL condition showed an average contact pressure of 84% greater than that of the native ligament group. Reconstruction of the UCL restored average articular pressures to within 20% of intact values at 90°. CONCLUSION: UCL injury increases radiocapitellar contact pressures and reduces resistance of the elbow to valgus loading. Contact pressures and valgus laxity can be improved with UCL reconstruction. DISCUSSION: Taken as a whole, the peak pressure data indicate that the reconstruction restores valgus stability and lateral contact pressures to nearly normal levels under the conditions tested. Because the 90 position is the clinically significant position, these laboratory data support the clinical success of the docking procedure.

Midterm results of a porous tantalum monoblock tibia component clinical and radiographic results of 108 knees.

The use of Trabecular Metal (TM), a biomaterial manufactured from elemental tantalum metal, has recently increased in orthopedics. One hundred eight consecutive TM monoblock tibias were implanted in 95 patients and followed for a minimum of 2 years. The average follow-up was 4.5 years. The average age was 65 years. The Knee Society score of 36 improved to 89. One hundred five of the knees were rated good/excellent, and 3 knees were rated poor. Two patellar revisions were performed for loose components and one for patellar misalignment. One patella fracture required open reduction and internal fixation. One femur was revised. There were no tibia revisions. There were no progressive radiographic lucencies. Midterm clinical and radiographic results of 108 consecutive TM tibia components have a high rate of success.

Characteristics and outcomes of upper gastrointestinal hemorrhage in a tertiary referral hospital.

BACKGROUND AND AIMS: Upper gastrointestinal hemorrhage remains a problem in spite of improved diagnosis and management. There is sparse knowledge of recent epidemiology and outcomes. We wanted to evaluate the characteristics and outcomes of patients with upper gastrointestinal hemorrhage over a 4-year period in a tertiary referral hospital. METHODS: We prospectively collected data on patients admitted with upper gastrointestinal hemorrhage to John Hunter Hospital between August 2004 and December 2008. Variables of interest included age, gender, co-morbidities, and time to endoscopy. Main outcomes included etiology, treatment, and survival. Variceal and non-variceal bleeds were analyzed separately. RESULTS: There were 792 admissions from 734 unique patients (61% male) with a mean age of 66 years. The most frequent causes of non-variceal bleeds (88%) included ulcers 265 (33%); Mallory Weiss tear 91 (11%); esophagitis 60 (8%), and malignancy 29 (4%). Most patients had one or more co-morbidity (74%). Transfusion was not employed in 41%. Overall mortality was 4.0% (5.4% in the variceal and 3.9% in the non-variceal group). Only 1.9% of patients had surgery. CONCLUSIONS: Patients presenting with upper gastrointestinal hemorrhage are overall elderly with significant co-morbidities. Our overall mortality and surgery rates are lower than in previously published international data.

Arsenic trioxide associated toothache.

Arsenic trioxide in the treatment of acute promyelocytic leukaemia is relatively safe with minimal side effects. Dental toxicities associated with its use are uncommon. We describe the first case report of toothache associated with arsenic trioxide. A 45-year-old male with relapsed APL was commenced on a treatment schedule of all-trans-retinoic acid 20mg four times a day for 14 days concurrent with a 10mg intravenous infusion of arsenic trioxide for 28 days. After 14 doses of the 6th cycle of treatment he experienced severe acute pain in various parts of the oral cavity. Extensive examination including an orthodontic review concluded there was no indication that the pain symptoms were due to a dental or endodontic cause. Four days after completing his 6th cycle the pain completely resolved. The mechanism of this adverse event remains unclear. Physicians with patients receiving arsenic trioxide with unexplained toothache should consider the arsenic as the cause of the pain.

Gastrointestinal hemorrhage: should we transfuse less?

Although blood transfusion has an established place in the conventional management of acute upper gastrointestinal (GI) hemorrhage, there is growing evidence of adverse side effects of transfusion, both acute and later. An Ovid Medline literature search was performed to evaluate the significance and importance of these effects. Evidence of impaired hemostasis with repletion of blood volume in the acute phase was found in multiple studies and in uncontrolled studies in combat casualties. There are multiple large studies of a so-called immunosuppressive effect of transfused blood leading to increased infection rates and mortality dependent both on dose and on the age of the stored blood. In view of evidence of increased bleeding with early blood volume restoration and the growing evidence of so-called immunosuppressive effects of stored blood, there is a need to consider trials using a conservative utilization of blood in acute GI bleeding.