The impact of bleeding on outcomes following lung transplantation: a retrospective analysis using the universal definition of perioperative bleeding.

BACKGROUND: Lung transplantation (LT) represents a high-risk procedure for end-stage lung diseases. This study describes the outcomes of patients undergoing LT that require massive transfusions as defined by the universal definition of perioperative bleeding (UDPB). METHODS: Adult patients who underwent bilateral LT at a single academic center were surveyed retrospectively. Patients were grouped by insignificant, mild, or moderate perioperative bleeding (insignificant-to-moderate bleeders) and severe or massive perioperative bleeding (severe-to-massive bleeders) based on the UDPB classification. Outcomes included 1-year survival and primary graft dysfunction (PGD) of grade 3 at 72 h postoperatively. Multivariable models were adjusted for recipient age, sex, body mass index (BMI), Lung allocation score (LAS), preoperative hemoglobin (Hb), preoperative extracorporeal membrane oxygenation (ECMO) status, transplant number, and donor status. An additional multivariable model was created to find preoperative and intraoperative predictors of severe-to-massive bleeding. A p-value less than 0.05 was selected for significance. RESULTS: A total of 528 patients were included, with 357 insignificant-to-moderate bleeders and 171 severe-to-massive bleeders. Postoperatively, severe-to-massive bleeders had higher rates of PGD grade 3 at 72 h, longer hospital stays, higher mortality rates at 30 days and one year, and were less likely to achieve textbook outcomes for LT. They also required postoperative ECMO, reintubation for over 48 h, tracheostomy, reintervention, and dialysis at higher rates. In the multivariate analysis, severe-to-massive bleeding was significantly associated with adverse outcomes after adjusting for recipient and donor factors, with an odds ratio of 7.73 (95% CI: 4.27-14.4, p < 0.001) for PGD3 at 72 h, 4.30 (95% CI: 2.30-8.12, p < 0.001) for 1-year mortality, and 1.75 (95% CI: 1.52-2.01, p < 0.001) for longer hospital stays. Additionally, severe-to-massive bleeders were less likely to achieve textbook outcomes, with an odds ratio of 0.07 (95% CI: 0.02-0.16, p < 0.001). Preoperative and intraoperative predictors of severe/massive bleeding were identified, with White patients having lower odds compared to Black patients (OR: 041, 95% CI: 0.22-0.80, p = 0.008). Each 1-unit increase in BMI decreased the odds of bleeding (OR: 0.89, 95% CI: 0.83-0.95, p < 0.001), while each 1-unit increase in MPAP increased the odds of bleeding (OR: 1.04, 95% CI: 1.02-1.06, p < 0.001). First-time transplant recipients had lower risk (OR: 0.16, 95% CI: 0.06-0.36, p < 0.001), whereas those with DCD donors had a higher risk of severe-to-massive bleeding (OR: 3.09, 95% CI: 1.63-5.87, p = 0.001). CONCLUSION: These results suggest that patients at high risk of massive bleeding require higher utilization of hospital resources. Understanding their outcomes is important, as it may inform future decisions to transplant comparable patients.

Use of a digital contact tracing system in Singapore to mitigate COVID-19 spread.

BACKGROUND: Contact tracing has been essential to reducing spread of COVID-19. Singapore leveraged technology to assist with contact tracing efforts using a Bluetooth-based app and token platform called 'TraceTogether'. METHODS: We reviewed the impact of this system during the country's Delta and Omicron waves (24 August 2021 to 17 February 2022) to identify differences in number of close contacts and time savings between full automation using TraceTogether alone as compared to manual contact tracing supplemented by TraceTogether. Characteristics of digital contact tracing app or token users were reviewed. Thereafter, the number of close contacts identified by manual and digital contact tracing methods, and the number of confirmed COVID-19 cases among contacts were analysed. The difference in time taken for identification of close contacts was also determined. FINDINGS: Adoption rate for TraceTogether was high, with 93.3% of cases having a registered device. There was a 9.8 h (34.9%) reduction in time savings for close contacts to be informed using TraceTogether alone compared to manual contact tracing supplemented by TraceTogether. The proportion of close contacts automatically identified through TraceTogether alone and turned positive was 3.6%. For those identified through manual contact tracing supplemented by TraceTogether, this proportion was 12.5% and 6.2% for those served quarantine orders and health risk warnings respectively. INTERPRETATION: The high adoption rate of 'TraceTogether' suggest that digital solutions remain a promising option to improve contact tracing in future epidemics. This may have been through its concurrent use with vaccine differentiated public health measures and policies which engender public trust. There is future potential for utilising such technology in managing communicable diseases to achieve good public health outcomes.

Textbook outcome in lung transplantation: Planned venoarterial extracorporeal membrane oxygenation versus off-pump support for patients without pulmonary hypertension.

BACKGROUND: Planned venoarterial extracorporeal membrane oxygenation (VA ECMO) is increasingly used during bilateral orthotopic lung transplantation (BOLT) and may be superior to off-pump support for patients without pulmonary hypertension. In this single-institution study, we compared rates of textbook outcome between BOLTs performed with planned VA ECMO or off-pump support for recipients with no or mild pulmonary hypertension. METHODS: Patients with no or mild pulmonary hypertension who underwent isolated BOLT between 1/2017 and 2/2021 with planned off-pump or VA ECMO support were included. Textbook outcome was defined as freedom from intraoperative complication, 30-day reintervention, 30-day readmission, post-transplant length of stay >30 days, 90-day mortality, 30-day acute rejection, grade 3 primary graft dysfunction at 48 or 72 hours, post-transplant ECMO, tracheostomy within 7 days, inpatient dialysis, reintubation, and extubation >48 hours post-transplant. Textbook outcome achievement was compared between groups using multivariable logistic regression. RESULTS: Two hundred thirty-seven BOLTs were included: 68 planned VA ECMO and 169 planned off-pump. 14 (20.6%) planned VA ECMO and 27 (16.0%) planned off-pump patients achieved textbook outcome. After adjustment for prior BOLT, lung allocation score, ischemic time, and intraoperative transfusions, planned VA ECMO was associated with higher odds of textbook outcome than planned off-pump support (odds ratio 3.89, 95% confidence interval 1.58-9.90, p = 0.004). CONCLUSIONS: At our institution, planned VA ECMO for isolated BOLT was associated with higher odds of textbook outcome than planned off-pump support among patients without pulmonary hypertension. Further investigation in a multi-institutional cohort is warranted to better elucidate the utility of this strategy.

Using touchscreen tablets to support social connections and reduce responsive behaviours among people with dementia in care settings: A scoping review.

The use of touchscreen tablets, such as the iPad, offers potential to support the person with dementia staying in a care setting, ranging from a long-term care home to an adult day programme. Although electronic devices are used among people with dementia, a comprehensive review of studies focusing on their impact and how they may be used effectively in care settings is lacking. We conducted a scoping review to summarize existing knowledge about the impact of touchscreen tablets in supporting social connections and reducing responsive behaviours of people with dementia in care settings. Our research team consists of patient partners and family partners, physicians, nurses, a medical student and an academic professor. A total of 17 articles were included in the review. Our analysis identified three ways in which touchscreen tablets support dementia care: (1) increased the person's engagement, (2) decreased responsive behaviours and (3) positive effect on enjoyment/quality of life for people with dementia. Lessons learned and barriers to the use of touchscreen tablets in the care of people with dementia are described. Overall, only a few studies delineated strategies that helped to overcome barriers to technology adoption in care settings. Knowledge translation studies are needed to identify effective processes and practical tips to overcome barriers and realize the potential of assistive technology in dementia care.

Creating a toolkit with stakeholders for leveraging tablet computers to support person-centred dementia care in hospitals.

INTRODUCTION: People with dementia may refuse care because they feel overwhelmed by an unfamiliar environment. Everyday technology such as tablets have the potential to support person-centred dementia care in hospitals. AIMS: We aimed to identify barriers and enabling factors in order to develop a toolkit to support the use of tablets in engaging individual and group activities, especially to play family videos, for hospitalized older people with dementia. METHODS: A participatory action research approach was employed. We facilitated staff focus groups and conducted interviews with stakeholders. A toolkit was developed based on participants' perspectives on how to support successful adoption. RESULTS: Our analysis identified two enabling factors: users' engagement in developing a toolkit for support and adapting implementation to meet local needs. Barriers included staff and family inexperience, mechanical instability of hardware, issues around privacy and data access, technology use and personalization of messages. The toolkit includes short videos, a brochure for family caregivers, and a pocket card for staff.Discussion and implications: Staff, family and patients start with varying levels of experience with the use of tablets, making education and support vitally important to implementation. Health organizations should involve staff, patients, and families to find practical solutions.

Use of touch screen tablets to support social connections and reduce responsive behaviours among people with dementia in care settings: a scoping review protocol.

INTRODUCTION: The disabilities associated with dementia make the adjustment to staying in a care setting stressful. Separation from family can exacerbate the effects of stress. The use of touch screen tablets such as an iPad may offer potential to support the person with dementia staying in a care setting. Although electronic devices are used among people with dementia for a variety of purposes, a comprehensive review of studies focusing on their impact in care settings for social connection and patient/resident behaviour is lacking. This scoping review will focus on the use of touch screen tablets to support social connections and reducing responsive behaviours of people with dementia while in a care setting, such as a hospital ward. METHODS AND ANALYSIS: This scoping review will follow Joanna Briggs Institute scoping review methodology. The review team consists of two patient partners and three family partners, a nurse researcher, a research assistant and an academic professor. All authors including patient and family partners were involved in preparing this scoping review protocol. In the scoping review, we will search the following databases: MEDLINE, AgeLine, Cochrane, CINAHL, PsycINFO and IEEE. Google and Google Scholar will be used to search for additional literature. A hand search will be conducted using the reference lists of included studies to identify additional relevant articles. Included studies must report on the impact of using a touch screen technology intervention that involves older adults with dementia in care settings, published in English since 2009. ETHICS AND DISSEMINATION: This review study does not require ethics approval. By examining the current state of using touch screen tablets to support older people with dementia in care settings, this scoping review can offer useful insight into users' needs (eg, patients' and care providers' needs) and inform future research and practice. We will share the scoping review results through conference presentations and an open access publication in a peer-reviewed journal.

The effect of concussion on batting performance of major league baseball players.

PURPOSE: Previous investigations into concussions' effects on Major League Baseball (MLB) players suggested that concussion negatively impacts traditional measures of batting performance. This study examined whether post-concussion batting performance, as measured by traditional, plate discipline, and batted ball statistics, in MLB players was worse than other post-injury performance. SUBJECTS AND METHODS: MLB players with concussion from 2008 to 2014 were identified. Concussion was defined by placement on the disabled list or missing games due to concussion, post-concussive syndrome, or head trauma. Injuries causing players to be put on the disabled list were matched by age, position, and injury duration to serve as controls. Mixed effects models were used to estimate concussion's influence after adjusting for potential confounders. The primary study outcome measurements were: traditional (eg, average), plate discipline (eg, swing-at-strike rate), and batted ball (eg, ground ball percentage) statistics. RESULTS: There were 85 concussed players and 212 controls included in the analyses. There was no significant difference in performance between concussed players and controls. However, concussed players started at a lower level of performance pre-event than the controls, striking out a 9.2% rate vs 8.2% (P=0.042) with an isolated power of 0.075 vs 0.082 (P=0.035). For concussed players, traditional batting statistics decreased before plate discipline metrics. CONCLUSION: MLB players' performance was lower after return from concussion, but no more than after return from other injuries. The decreased performance prior to concussion suggests that concussion-related performance declines may not be due exclusively to concussion and perhaps point to risk factors predisposing to concussion.

The relationship between arterial stiffness and heart failure with preserved ejection fraction: a systemic meta-analysis.

The objective is to investigate the relationship between arterial stiffness measured by arterial tonometry and echocardiographic indices of diastolic dysfunction-a basis for the diagnosis of heart failure with preserved ejection fraction (HFpEF). OvidSP Medline, Embase and PubMed were systematically searched. Eligible articles correlated arterial stiffness measured by brachial-ankle pulse wave velocity (baPWV), carotid-femoral pulse wave velocity (cfPWV), augmentation index (AIx) or cardio-ankle vascular index (CAVI) with indices of diastolic dysfunction, E/A ratio, peak early mitral annular velocity (e') and E/e' ratio. Correlation coefficients were determined using a random-effects model. Twenty-seven studies with 6,626 patients were included. baPWV was significantly correlated with E/A ratio (r = -0.434, 95 % CI -0.387 to -0.479), e' (r = -0.499, 95 % CI -0.448 to -0.548) and E/e' ratio (r = 0.372, 95 % CI 0.251-0.481). cfPWV was significantly correlated with E/A ratio (r = -0.391, 95 % CI -0.304 to -0.470) and E/e' ratio (r = 0.210, 95 % CI 0.300-0.116), but not e'. AIx was significantly correlated with E/A ratio (r = -0.356, 95 % CI -0.255 to -0.450), e' (r = -0.313, 95 % CI -0.195 to -0.423) and E/e' ratio (r = 0.321, 95 % CI 0.250-0.388). CAVI was significantly correlated with E/A ratio (r = -0.405, CI -0.324 to -0.481), e' (r = -0.449, 95 % CI -0.340 to -0.630), but not E/e'. baPWV showed significantly greater correlation with diastolic dysfunction compared to most other tonometric techniques. Arterial stiffness measured by arterial tonometry is an indicator of diastolic dysfunction with baPWV demonstrated the most consistent and strongest association. These data suggest a refocusing on the impact of arterial stiffness on the left ventricle as a potential causative factor leading to HFpEF.

Pulse wave velocity involving proximal portions of the aorta correlates with the degree of aortic dilatation at the sinuses of valsalva in ascending thoracic aortic aneurysms.

OBJECTIVE: To determine the relationship between arterial stiffness measured in different aortic segments and the presence and extent of ascending thoracic aortic aneurysm (ATAA). METHODS: Patients at a Thoracic Aortic Diseases clinic at a University teaching hospital were compared to patients attending a Cardiology outpatient Clinic at the same institution. A non-invasive measure of vascular stiffness was performed using pulse wave velocity (PWV) measurement of several vascular segments-carotid-femoral pulse wave velocity (cfPWV), heart-femoral pulse wave velocity (hfPWV) and brachial-ankle pulse wave velocity (baPWV). Aortic dimensions were measured on echocardiogram. RESULTS: Patients with ATAA (N = 32) were 66 years and the same age as those without ATAA (N = 46). There was no significant difference between those with or without aortic aneurysm with respect to cfPWV, hfPWV or baPWV. In ATAA, there was a significant (p <0.05) inverse correlation between aortic diameter at the sinuses of Valsalva and cfPWV, as well as hfPWV, but not with baPWV. This relationship was not evident in persons without ATAA. CONCLUSION: Reduced aortic stiffness (increased compliance), assessed by cfPWV or hfPWV, correlates with larger aortic size of ATAA at the level of the sinuses of Valsalva but not at the ascending aorta, suggesting cfPWV may be a useful method to assess the size of ATAA at the level of the sinuses of Valsalva. Overall aortic stiffness assessed by PWV did not differentiate persons with or without an ATAA, in individuals who do not have a genetic or inheritable cause of their ATAA.

Brachial-ankle pulse wave velocity is the only index of arterial stiffness that correlates with a mitral valve indices of diastolic dysfunction, but no index correlates with left atrial size.

The objective of this study was to determine the optimal assessment of arterial stiffness that relates to diastolic dysfunction. Forty-one patients had measurements of brachial-ankle pulse wave velocity (baPWV), carotid-femoral pulse wave velocity (cfPWV), ankle brachial index (ABI), pulse pressure (PP), and augmentation index (AIx). Diastolic dysfunction was evaluated by echocardiographic indices of the ratio of the peak early diastolic mitral valve velocity and the peak late diastolic velocity (E/A ratio), left atrial diameter, and left atrial volume indexes. There was a significant (P < 0.05) correlation between baPWV and E/A ratio with an inverse relationship indicating that higher arterial stiffness was associated with greater diastolic dysfunction. In contrast, there was no significant correlation between E/A ratio and cfPWV, PP, ABI, or AIx. After multivariate analysis, the relationship between baPWV and E/A ratio remained significant (P < 0.05), independent of age and systolic blood pressure (BP). There were no correlations between any index of vascular stiffness and left atrial dimension or volume. In summary, baPWV correlates with diastolic dysfunction, independent of a patient's age and BP and is a better indicator of diastolic dysfunction than other indicators of arterial stiffness. baPWV has the utility of infering the presence of left ventricular diastolic dysfunction.

Thromboembolic events in patients on extracorporeal membrane oxygenation without anticoagulation.

OBJECTIVE: : Heparinization is thought to be mandatory to avoid thromboembolic complications during venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, bleeding complications are common. We report our experience of VA-ECMO without systemic anticoagulation. METHODS: : A prospectively assembled database describing all ECMO cases from 2000 to 2008 was analyzed. A heparin coated circuit (Medtronic, Inc., Minneapolis, MN USA) and membrane oxygenator (Quadrox D Bioline oxygenator; MAQUET, Rastatt, Germany) were used in all cases. After the initiation of VA-ECMO support, all coagulation parameters were corrected. No further systemic maintenance anticoagulant was given, except at the time of weaning. RESULTS: : Thirty-two patients received VA-ECMO support; 20 patients (62.5%) were males with a median age of 52.5 years (interquartile range, 40.4-61.1 years). Central and peripheral cannulations were 53% and 47%, respectively. Etiologies of cardiogenic shock were postcardiotomy (75%, n = 24) and as a support to cardiopulmonary resuscitation in 25% of cases (n = 8). Thirty-day mortality was 43.8%. Median duration of ECMO support was 46.3 hours (interquartile range, 26.8-87.8 hours). The median number of packed red blood cell transfusions was 18 ± 25. Complications include five patients (16%) with limb ischemia requiring intervention, 15 patients (46.9%) had acute renal failure, two patients had deep vein thrombosis, and two patients had intracardiac clots detected on echocardiograms. No patient had a cerebrovascular event. Incidence of membrane oxygenator failure was low, requiring replacement in three patients; no adverse event occurred during replacement. Fourteen patients (43.8%) were reexplored for bleeding. Fourteen patients (44%) were discharged home and were long-term survivors. CONCLUSIONS: : VA-ECMO support without systemic anticoagulation may reduce bleeding complications and transfusion requirement, without increasing the risk of thromboembolism.