Consensus statement on the interhospital transfer of patients with acute aortic syndrome: TRAVERSING Delphi study.

BACKGROUND: Standardisation of referral pathways and the transfer of patients with acute aortic syndromes (AAS) to regional centres are recommended by NHS England in the Acute Aortic Dissection Toolkit. The aim of the Transfer of Thoracic Aortic Vascular Emergencies to Regional Specialist INstitutes Group study was to establish an interdisciplinary consensus on the interhospital transfer of patients with AAS to specialist high-volume aortic centres. METHODS: Consensus on the key aspects of interhospital transfer of patients with AAS was established using the Delphi method, in line with Conducting and Reporting of Delphi Studies guidelines. A national patient charity for aortic dissection was involved in the design of the Delphi study. Vascular and cardiothoracic surgeons, emergency physicians, interventional radiologists, cardiologists, intensivists and anaesthetists in the United Kingdom were invited to participate via their respective professional societies. RESULTS: Three consecutive rounds of an electronic Delphi survey were completed by 212, 101 and 58 respondents, respectively. Using predefined consensus criteria, 60 out of 117 (51%) statements from the survey were included in the consensus statement. The study concluded that patients can be taken directly to a specialist aortic centre if they have typical symptoms of AAS on the background of known aortic disease or previous aortic intervention. Accepted patients should be transferred in a category 2 ambulance (response time <18 min), ideally accompanied by transfer-trained personnel or Adult Critical Care Transfer Services. A clear plan should be agreed in case of a cardiac arrest occurring during the transfer. Patients should reach the aortic centre within 4 hours of the initial referral from their local hospital. CONCLUSIONS: This consensus statement is the first set of national interdisciplinary recommendations on the interhospital transfer of patients with AAS. Its implementation is likely to contribute to safer and more standardised emergency referral pathways to regional high-volume specialist aortic units.

The Impact of the Covid-19 Pandemic on Recovery from Cardiac Surgery Over Time: Results of the Cardiaccovid Study from three Uk National Lockdowns.

This prospective study (clinicaltrials.gov NCT04366167) explores health-related quality of life (EQ-5D-5L), event-related distress (IES-R) and depression (CES-D) after cardiac surgery during the three UK national COVID-19 lockdowns. Overall, 253 patients participated (lockdown one n = 196; two n = 45; three n = 12) completing the above-mentioned questionnaires at baseline, one week after discharge and six weeks, six and 12 months after surgery. While EQ-5D-5L values were similar across all cohorts, those having surgery in lockdowns two and three had higher IES-R scores at 1-year and higher IES-R and CES-D baseline scores, respectively. Generally, increased distress, worse depression and poorer HRQoL were observed in women.

The impact of the COVID-19 pandemic on recovery from cardiac surgery: 1-year outcomes.

AIMS: The outbreak of COVID-19 was potentially stressful for everyone and possibly heightened in those having surgery. We sought to explore the impact of the pandemic on recovery from cardiac surgery. METHODS AND RESULTS: A prospective observational study of 196 patients who were ≥18years old undergoing cardiac surgery between March 23 and July 4, 2020 (UK lockdown) was conducted. Those too unwell or unable to give consent/complete the questionnaires were excluded. Participants completed (on paper or electronically) the impact of event [Impact of Events Scale-revised (IES-R)] (distress related to COVID-19), depression [Centre for Epidemiological Studies Depression Scale (CES-D)], and EQ-5D-5L [(quality of life, health-related quality of life (HRQoL)] questionnaires at baseline, 1 week after hospital discharge, and 6 weeks, 6 months and 1 year post-surgery. Questionnaire completion was >75.0% at all timepoints, except at 1 week (67.3%). Most participants were male [147 (75.0%)], white British [156 (79.6%)] with an average age 63.4years. No patients had COVID-19. IES-R sand CES-D were above average at baseline (indicating higher levels of anxiety and depression) decreasing over time. HRQoL pre-surgery was high, reducing at 1 week but increasing to almost pre-operative levels at 6 weeks and exceeding pre-operative levels at 6 months and 1 year. IES-R and CES-D scores were consistently higher in women and younger patients with women also having poorer HRQoL up to 1-year after surgery. CONCLUSIONS: High levels of distress were observed in patients undergoing cardiac surgery during the COVID-19 pandemic with women and younger participants particularly affected. Psychological support pre- and post-operatively in further crises or traumatic times should be considered to aid recovery. REGISTRATION: Clinicaltrials.gov ID:NCT04366167.

Evaluating the Feasibility of Screening Relatives of Patients Affected by Nonsyndromic Thoracic Aortic Diseases: The REST Study.

Background Diseases of the thoracic aorta are characterized by a familial etiology in up to 30% of the cases. Nonsyndromic thoracic aorta diseases (NS-TADs) lack overt clinical signs and systemic features, which hinder early detection and prompt surgical intervention. We hypothesize that tailored genetic testing and imaging of first-degree and second-degree relatives of patients affected by NS-TADs may enable early diagnosis and allow appropriate surveillance or intervention. Methods and Results We conducted a feasibility study involving probands affected by familial or sporadic NS-TADs who had undergone surgery, which also offered screening to their relatives. Each participant underwent a combined imaging (echocardiogram and magnetic resonance imaging) and genetic (whole exome sequencing) evaluation, together with physical examination and psychological assessment. The study population included 16 probands (8 sporadic, 8 familial) and 54 relatives (41 first-degree and 13 second-degree relatives) with median age 48 years (range: 18-85 years). No syndromic physical features were observed. Imaging revealed mild-to-moderate aortic dilation in 24% of relatives. A genetic variant of uncertain significance was identified in 3 families. Imaging, further phenotyping, or a form of secondary prevention was indicated in 68% of the relatives in the familial group and 54% in the sporadic group. No participants fulfilled criteria for aortic surgery. No differences between baseline and 3-month follow-up scores for depression, anxiety, and self-reported quality of life were observed. Conclusions In NS-TADs, imaging tests, genetic counseling, and family screening yielded positive results in up to 1 out of 4 screened relatives, including those in the sporadic NS-TAD group. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03861741.

COVID-19 and cardiac surgery: A perspective from United Kingdom.

The emergence of severe acute respiratory syndrome coronavirus 2 in December 2019, presumed from the city of Wuhan, Hubei province in China, and the subsequent declaration of the disease as a pandemic by the World Health Organization as coronavirus disease 2019 (COVID-19) in March 2020, had a significant impact on health care systems globally. Each country responded to this disease in different ways, however this was done broadly by fortifying and prioritizing health care provision as well as introducing social lockdown aiming to contain the infection and minimizing the risk of transmission. In the United Kingdom, a lockdown was introduced by the government on March 23, 2020 and all health care services were focussed to challenge the impact of COVID-19. To do so, the United Kingdom National Health Service had to undergo widespread service reconfigurations and the so-called "Nightingale Hospitals" were created de novo to bolster bed provision, and industries were asked to direct efforts to the production of ventilators. A government-led public health campaign was publicized under the slogan of: "Stay home, Protect the NHS (National Health Service), Save lives." The approach had a significant impact on the delivery of all surgical services but particularly cardiac surgery with its inherent critical care bed capacity. This paper describes the impact on provision for elective and emergency cardiac surgery in the United Kingdom, with a focus on aortovascular disease. We describe our aortovascular activity and outcomes during the period of UK lockdown and present a patient survey of attitudes to aortic surgery during COVID-19 pandemic.

In vitro dentine tubule occlusion by a novel toothpaste containing calcium silicate and sodium phosphate.

OBJECTIVES: To investigate the deposition, formation of hydroxyapatite (HAP) and acid resistance of dentine surfaces following brushing with a toothpaste containing calcium silicate and sodium phosphate (CSSP) and fluoride in vitro. METHODS: Human dentine specimens were brushed with a slurry of CSSP toothpaste followed by exposure to simulated oral fluid (SOF) in two in vitro studies, with a silica-based non-occluding toothpaste as control. The surface and tubule deposits were analysed after 14 cycles with scanning electron microscopy (SEM), energy dispersive x-ray spectroscopy (EDX), transmission electron microscopy (TEM) and selected area electron diffraction (SAED). In a third study, dentine specimens were additionally exposed to citric acid erosive challenges for 30, 300 or 600 s after 2, 6, 10 and 14 cycles of SOF and either the CSSP toothpaste or a positive control toothpaste containing calcium sodium phosphosilicate and fluoride. The level of tubule occlusion was evaluated using SEM. RESULTS: The SEM analyses indicated complete coverage of the dentine surface following 14 cycles of brushing with CSSP toothpaste with no observable patent tubules, in contrast to the non-occluding control toothpaste. The TEM and SAED analyses confirmed the deposited material on the surface and within tubules was HAP. The deposited material from CSSP toothpaste was more acid resistant than the deposited material from the positive control toothpaste at all time points and acid exposure levels (p < 0.05). CONCLUSIONS: The CSSP toothpaste fully occluded dentine tubules and formed the mineral HAP. The dentine deposition on and within dentine tubules was resilient to acid erosive challenges. CLINICAL SIGNIFICANCE: A novel toothpaste containing CSSP can form HAP on dentine surfaces and within tubules. The potential of this technology is for a novel approach for the protection of dentine surfaces to acid challenges and the reduction of dentine hypersensitivity.

Towards modular bone tissue engineering using Ti-Co-doped phosphate glass microspheres: cytocompatibility and dynamic culture studies.

The production of large quantities of functional vascularized bone tissue ex vivo still represent an unmet clinical challenge. Microcarriers offer a potential solution to scalable manufacture of bone tissue due to their high surface area-to-volume ratio and the capacity to be assembled using a modular approach. Microcarriers made of phosphate bioactive glass doped with titanium dioxide have been previously shown to enhance proliferation of osteoblast progenitors and maturation towards functional osteoblasts. Furthemore, doping with cobalt appears to mimic hypoxic conditions that have a key role in promoting angiogenesis. This characteristic could be exploited to meet the clinical requirement of producing vascularized units of bone tissue. In the current study, the human osteosarcoma cell line MG-63 was cultured on phosphate glass microspheres doped with 5% mol titanium dioxide and different concentrations of cobalt oxide (0%, 2% and 5% mol), under static and dynamic conditions (150 and 300 rpm on an orbital shaker). Cell proliferation and the formation of aggregates of cells and microspheres were observed over a period of two weeks in all glass compositions, thus confirming the biocompatibility of the substrate and the suitability of this system for the formation of compact micro-units of tissue. At the concentrations tested, cobalt was not found to be cytotoxic and did not alter cell metabolism. On the other hand, the dynamic environment played a key role, with moderate agitation having a positive effect on cell proliferation while higher agitation resulting in impaired cell growth. Finally, in static culture assays, the capacity of cobalt doping to induce vascular endothelial growth factor (VEGF) upregulation by osteoblastic cells was observed, but was not found to increase linearly with cobalt oxide content. In conclusion, Ti-Co phosphate glasses were found to support osteoblastic cell growth and aggregate formation that is a necessary precursor to tissue formation and the upregaulation of VEGF production can potentially support vascularization.

Evidence of an in vitro Coupled Diffusion Mechanism of Lesion Formation within Microcosm Dental Plaque.

The purpose of this study was to determine whether or not the dual constant-depth film fermenter (dCDFF) is able to produce caries-like enamel lesions and to ascertain further information regarding the performance of this fully functional biological caries model. Conditions were defined by the continuation (CF) or cessation (FF) of a saliva-type growth medium supply during 50-mM sucrose exposures (8 times daily). Hydroxyapatite (n = 3) and bovine enamel (n = 3) substrata were included within each condition and samples extracted after 2, 4, 8, and 16 days. Community profiles were generated for fastidious anaerobes, Lactobacillus spp., Streptococcus spp., mutans streptococci (MS), and Veillonella spp. using selective culture techniques and enamel demineralisation assessed by transverse microradiography. Results demonstrated that the dCDFF model is able to produce caries-like enamel lesions with a high degree of sensitivity where reduced ionic strength within the FF condition increased surface layer mineral deposition. Between conditions, biofilm communities did not differ significantly, although MS in the biofilms extracted from the FF condition rose to a higher proportion (by 1.5 log10 units), and Veillonella spp. were initially greater within the CF condition (by 2.5 log10 units), indicating an enhanced ability for the clearance of low-pKa acids following exposures to sucrose. However, both conditions retained the ability for caries-like lesion formation.

Sol-gel synthesis of quaternary (P2O5)55-(CaO)25-(Na2O)(20-x)-(TiO2) x bioresorbable glasses for bone tissue engineering applications (x = 0, 5, 10, or 15).

In the present study, we report a new and facile sol-gel synthesis of phosphate-based glasses with the general formula of (P2O5)55-(CaO)25-(Na2O)(20-x)-(TiO2) x , where x = 0, 5, 10 or 15, for bone tissue engineering applications. The sol-gel synthesis method allows greater control over glass morphology at relatively low processing temperature (200 °C) in comparison with phosphate-based melt-derived glasses (~1000 °C). The glasses were analyzed using several characterization techniques, including x-ray diffraction (XRD), (31)P magic angle spinning nuclear magnetic resonance ((31)P MAS-NMR), Fourier transform infrared (FTIR) spectroscopy and energy-dispersive x-ray (EDX) spectroscopy, which confirmed the amorphous and glassy nature of the prepared samples. Degradation was assessed by measuring the ion release and pH change of the storage medium. Cytocompatibility was also confirmed by culturing osteoblast-like osteosarcoma cell line MG-63 on the glass microparticles over a seven-day period. Cell attachment to the particles was imaged using scanning electron microscopy (SEM) and confocal laser scanning microscopy (CLSM). The results revealed the potential of phosphate-based sol-gel derived glasses containing 5 or 10 mol% TiO2, with high surface area, ideal dissolution rate for cell attachment and easily metabolized dissolution products, for bone tissue engineering applications.

Strontium- and calcium-containing, titanium-stabilised phosphate-based glasses with prolonged degradation for orthopaedic tissue engineering.

Strontium- and calcium-releasing, titanium-stabilised phosphate-based glasses with a controlled degradation rate are currently under development for orthopaedic tissue engineering applications. Ca and/or Sr were incorporated at varying concentrations in quaternary phosphate-based glasses, in order to promote osteoinduction. Ti was incorporated at a fixed concentration in order to prolong degradation. Glasses of the general formula (P2O5)-(Na2O)-(TiO2)-(CaO)-(SrO) were prepared via the melt-quench technique. The materials were characterised by energy-dispersive X-ray spectroscopy, X-ray diffraction, (31)P magic angle spinning nuclear magnetic resonance, Fourier transform infrared spectroscopy, differential thermal analysis and density determination. The dissolution rate in distilled water was determined by measuring mass loss, ion release and pH change over a two-week period. In addition, the cytocompatibility and alkaline phosphatase activity of an osteoblast-like cell line cultured on the surface of glass discs was assessed. The glasses were shown to be amorphous and contained Q(1), Q(2) and Q(3) species. Fourier transform infrared spectroscopy revealed small changes in the glass structure as Ca was substituted with Sr and differential thermal analysis confirmed a decrease in crystallisation temperature with increasing Sr content. Degradation and ion release studies also showed that mass loss was positively correlated with Sr content. These results were attributed to the lower electronegativity of Sr in comparison to Ca favouring the formation of phosphate-based mineral phases. All compositions supported cell proliferation and survival and induced at least 2.3-fold alkaline phosphatase activity relative to the control. Glass containing 17.5 mol% Sr had 3.6-fold greater alkaline phosphatase activity than the control. The gradual release of Ca and Sr supported osteoinduction, indicating their potential suitability in orthopaedic tissue engineering applications.

Role of gallium and silver from phosphate-based glasses on in vitro dual species oral biofilm models of Porphyromonas gingivalis and Streptococcus gordonii.

Phosphate-based glasses (PBGs) are excellent controlled delivery agents for antibacterial ions such as silver and gallium. The aim of this study was to assess the potential utility of novel PBGs combining both gallium and silver for use in periodontal therapy. To this end, an in vitro biofilm model with the putative periodontal pathogen, Porphyromonas gingivalis, and an initial colonizer, Streptococcus gordonii, was established. The effect of increasing calcium content in gallium-silver-doped PBG on the susceptibility of P. gingivalis was examined. A decrease in degradation rates (30.34, 25.19, 21.40 µg mm(-2) h(-1)) with increasing PBG calciumcontent (10, 11, 12 mol.% respectively) was observed, correlating well with gallium and silver ion release and antimicrobial activity against planktonic P. gingivalis (approximately 5.4log(10) colony-forming units (CFU) reduction after 24h by the C10 glass compared with controls) and S. gordonii (total growth inhibition after 32h by C10, C11 and C12 glasses compared with controls). The most potent PBG (C10) was evaluated for its ability to inhibit the biofilm growth of P. gingivalis in a newly established constant-depth film fermentor model. The simultaneous release of silver and gallium from the glass reduced P. gingivalis biofilm growth with a maximum effect (1.92log(10) CFU reduction) after 168 h. Given the emergence of antibiotic-resistant bacteria and dearth of new antibiotics in development, the glasses, especially C10, would offer effective alternatives to antibiotics or may complement current therapies through controlled, localized delivery of gallium and silver ions at infected sites in the oral cavity.

The feasibility and effectiveness of mindfulness-based cognitive therapy for mixed diagnosis patients in primary care: a pilot study.

Background Mindfulness-based cognitive therapy (MBCT) is an intervention developed for the prevention of recurrent depression which is now being applied to widening numbers of clinical populations. Despite evidence for its effectiveness in preventing relapse in depression, less is known about its efficacy within routine clinical practice for groups of patients with more varied mental health problems, despite this being a potentially promising context for its application. Aims This pilot study aimed to investigate whether MBCT would be feasible and effective when delivered in a primary care context for patients who are vulnerable to recurrent depression and anxiety. Results Attrition from the programme was low and both attendance and engagement with home practices (during and after the intervention) were comparable with or higher than those observed in the existing literature. Improvements in self-reported depression, anxiety, rumination, self-compassion and well-being were evident over the 8-week programme and at 6-month post intervention follow-up. Conclusions Despite limitations in terms of sample size and the absence of a control group, the results demonstrate that the promising research results of MBCT for depression are transferable from a research to a practice setting, and demonstrate that it may be an effective and feasible intervention when delivered in a primary care setting for a range of mental health problems.

Orchid bees as bio-indicators for organic coffee farms in Costa Rica: does farm size affect their abundance?

The potential of Euglossini bees, especially Euglossa, as biological indicators of organic vs nonorganic coffee farms was studied in Atenas and San Isidro, Alajuela, Costa Rica using 1.8-cineole as lure. Observations were made for three days at each of four farms and complemented with data from a year of observations. Orchid bees were in greater abundance in the organic farms (t-Student test). However, lower abundances suggest that an organic farm may be negatively affected by the proximity of non-organic farms, depending on its size and distance. Orchid bees may be indicators of organic coffee farms.

Por un año estudiamos las abejas de la tribu Euglossini (abejas de las orquídeas, especialmente el género Euglossa) en Atenas y San Isidro, Alajuela, Costa Rica, para identificar su potencial como bioindicadoras de fincas orgánicas y fincas “convencionales” de café. Usamos como atrayente aceite de eucalipto (1.8-cineole). Las abejas son más abundantes en las fincas de café orgánico (t-Student). Sin embargo, el relativamente bajo número de abejas en la menor de las dos fincas orgánicas sugiere que el tamaño de una finca orgánica y la proximidad a las fincas convencionales, podrían tener efectos negativos en la orgánica. Estas abejas podrían servir como bioindicadores de fincas orgánicas.

Orchid bees as bio-indicators for organic coffee farms in Costa Rica: does farm size affect their abundance?

The potential of Euglossini bees, especially Euglossa, as biological indicators of organic vs nonorganic coffee farms was studied in Atenas and San Isidro, Alajuela, Costa Rica using 1.8-cineole as lure. Observations were made for three days at each of four farms and complemented with data from a year of observations. Orchid bees were in greater abundance in the organic farms (t-Student test). However, lower abundances suggest that an organic farm may be negatively affected by the proximity of non-organic farms, depending on its size and distance. Orchid bees may be indicators of organic coffee farms.