Clinical application of intrapulmonary percussive ventilation: A scoping review.

Impaired respiratory function secondary to acute or chronic respiratory disease poses a significant clinical and healthcare burden. Intrapulmonary percussive ventilation (IPV) is used in various clinical settings to treat excessive airway secretions, pulmonary atelectasis, and impaired gas exchange. Despite IPV's wide use, there is a lack of clinical guidance on IPV application which may lead to inconsistency in clinical practice. This scoping review aimed to summarise the clinical application methods and dosage of IPV used by clinicians and researchers to provide guidance. A two-staged systematic search was conducted to retrieve studies that used IPV in inpatient and outpatient settings. MEDLINE, EMBASE, CINAHL, Scopus, and Google scholar were searched from January 1979 till 2022. Studies with patients aged ≥16 years and published in any language were included. Two reviewers independently screened the title and abstract, reviewed full text articles, and extracted data. Search yielded 514 studies. After removing duplicates and irrelevant studies, 25 studies with 905 participants met the inclusion criteria. This is the first scoping review to summarise IPV application methods and dosages from the available studies in intensive care unit (ICU), acute inpatient (non-ICU), and outpatient settings. Some variations in clinical applications and prescribed dosages of IPV were noted. Despite variations, common trends in clinical application and prescription of IPV dosages were observed and summarised to assist clinicians with IPV intervention. Although an evidence-based clinical guideline could not be provided, this review provides detailed information on IPV application and dosages in order to provide clinical guidance and lays a foundation towards developing a clinical practice guideline in the future.

A Retrospective Cohort Study of Red Cell Alloimmunisation in Rural, Remote, and Aboriginal and Torres Strait Islander Peoples Admitted to Intensive Care in the Northern Territory, Australia.

Red cell (RC) alloantibodies occur on exposure to non-self RC antigens in transfusion and pregnancy (typically IgG and clinically significant) or in association with non-RC immune environmental factors (typically IgM and not clinically significant). In Australia, the risk of RC alloimmunisation in First Nations peoples is unknown. We assessed the epidemiology, specificity, and antecedents of RC alloimmunisation via a data linkage retrospective cohort study of Northern Territory (NT) intensive care unit (ICU) patients (2015-2019). Of 4183 total patients, 50.9% were First Nations. In First Nations versus non-First Nations patients, the period prevalence of alloimmunisation was 10.9% versus 2.3%, with 390 versus 72 prevalent alloantibodies detected in 232 versus 48 alloimmunised patients, of which 135 (34.6%) versus 52 (72.2%) were clinically significant specificities. Baseline and follow-up alloantibody testing were available for 1367 patients, in whom new incident clinically significant alloantibodies developed in 4.5% First Nations versus 1.1% non-First Nations patients. On Cox proportional hazards modelling, adjusted hazard ratios (HR) showed First Nations status (HR 2.67 (95% CI 1.05-6.80), p = 0.04) and cumulative RC unit transfusion exposure (HR 1.03 (95% CI 1.01-1.05), p = 0.01) were independent predictors of clinically significant alloimmunisation. First Nations Australian patients are at increased risk of alloimmunisation due to RC transfusion, underscoring the importance of very judicious use of RC transfusions and shared decision-making with patients. Further studies are recommended to explore the role of other (non-RC) immune host factors, given the relative high prevalence of non-clinically significant IgM alloantibodies within alloimmunised First Nations patients.

Broadening the reach of dementia risk-reduction initiatives: strategies from dissemination models.

BACKGROUND: Modifiable risk factors for dementia account for 40% of cases worldwide and exert impacts on risk across the life course. To have maximal public health impact, dementia risk-reduction initiatives need to reach a large and diverse audience, including people from a wide range of ages and socioeconomic backgrounds. Currently, dementia risk-reduction interventions primarily reach a narrow audience, consisting largely of highly educated older adults from high income countries. METHODS: In this commentary, we review established dissemination models to identify strategies that could be used to extend and broaden the reach of dementia risk-reduction initiatives. Three potential reach-broadening strategies can be identified from these models: engaging with distinct user groups; focusing on interpersonal communication; and utilising dissemination agents. RESULTS: Engaging with distinct user groups and utilising dissemination agents show promise for broadening the reach of dementia risk-reduction initiatives, while interpersonal communication has received limited attention in this context. Further evaluation of the impact of interpersonal communication may provide avenues to take advantage of this dissemination method. CONCLUSIONS: Based on the reviewed models and data from current risk-reduction initiatives, we suggest that utilising all three of these strategies may most effectively broaden the reach of dementia risk-reduction initiatives. This may promote risk reduction among a larger and more diverse audience, more equitably reducing the global impact of dementia.

Measurement of snoring and stertor using the Sonomat to assess effectiveness of upper airway surgery in children.

STUDY OBJECTIVES: The success of surgical treatment for pediatric sleep-disordered breathing is typically assessed using the mixed and obstructive apnea-hypopnea index (MOAHI). Although an important metric, previous work has shown that snoring and stertor are also associated with sleep disruption. Our aim was to assess the efficacy of surgery using the Sonomat (Sonomedical Pty Ltd), a noncontact sleep assessment system, that accurately records complete and partial upper airway obstruction. METHODS: Forty children (< 18 years) had a Sonomat study, in their own beds, before and after surgery. As an MOAHI ≥ 1 event/h is considered abnormal, the same threshold was applied to snore/stertor runs. Median (interquartile range) values are reported. RESULTS: Respiratory event-induced movements decreased from 12.0 (8.7-19.0) to 0.5 (0.1-3.2) events/h (P < .01), with no significant change in spontaneous movements: 12.8 (9.8-17.9) to 16.5 (13.7-26.1) events/h (P = .07). The MOAHI decreased from 4.5 (1.9-8.6) to 0.0 (0.0-0.4) events/h (P < .01). Snoring and/or stertor runs decreased from 32.8 (23.4-44.4) to 3.0 (0.2-14.6) events/h (P < .01). Thirty-four children had an MOAHI < 1 event/h following surgery; however, 20 had snore and/or stertor runs ≥ 1 event/h and 11 had snore and/or stertor runs ≥ 5 events/h. Only 14 (35%) children had a postsurgery MOAHI < 1 event/h combined with snoring and/or stertor < 1 runs/h. CONCLUSIONS: Although surgery is effective in improving breathing, success rates are overestimated using the MOAHI. Our results indicate that snoring and/or stertor are still present at levels that may disrupt sleep despite a normalization of the MOAHI and that when obstructed breathing was objectively measured, there was a large variation in its response to surgery. CITATION: Norman MB, Harrison HC, Sullivan CE, Milross MA. Measurement of snoring and stertor using the Sonomat to assess effectiveness of upper airway surgery in children. J Clin Sleep Med. 2022;18(6):1649-1656.

Heart rate: control mechanisms, pathophysiology and assessment of the neurocardiac system in health and disease.

The monitoring of physiological function and dysfunction is an important principle in modern medicine. Heart rate is a basic example of this type of observation, particularly assessing the neurocardiac system, which entails the autonomic nervous system and intracardiac processes. The neurocardiac axis is an underappreciated and often overlooked system which, if measured appropriately in the clinical setting, may allow identification of patients at risk of disease progression and even mortality. While heart rate itself is a simplistic tool, more information may be gathered through assessing heart rate variability and heart rate recovery time. Studies have demonstrated an association of slow heart rate recovery and lower heart rate variability as markers of elevated sympathetic and lower parasympathetic tone. These parameters have additionally been shown to relate to development of arrhythmia, heart failure, systemic inflammatory processes, ischaemic heart disease and an increased rate of mortality. The aim of this review is to detail how heart rate is homeostatically controlled by the autonomic nervous system, how heart rate can impact on pathophysiological processes, and how heart rate variability and heart rate recovery time may be used in the clinical setting to allow the neurocardiac system to be assessed.

Interventions for preventing mastitis after childbirth.

BACKGROUND: Despite the health benefits of breastfeeding, initiation and duration rates continue to fall short of international guidelines. Many factors influence a woman's decision to wean; the main reason cited for weaning is associated with lactation complications, such as mastitis. Mastitis is an inflammation of the breast, with or without infection. It can be viewed as a continuum of disease, from non-infective inflammation of the breast to infection that may lead to abscess formation. OBJECTIVES: To assess the effectiveness of preventive strategies (for example, breastfeeding education, pharmacological treatments and alternative therapies) on the occurrence or recurrence of non-infective or infective mastitis in breastfeeding women post-childbirth. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (3 October 2019), and reference lists of retrieved studies. SELECTION CRITERIA: We included randomised controlled trials of interventions for preventing mastitis in postpartum breastfeeding women. Quasi-randomised controlled trials and trials reported only in abstract form were eligible. We attempted to contact the authors to obtain any unpublished results, wherever possible.  Interventions for preventing mastitis may include: probiotics, specialist breastfeeding advice and holistic approaches.   DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and assessed the certainty of the evidence using GRADE. MAIN RESULTS: We included 10 trials (3034 women). Nine trials (2395 women) contributed data. Generally, the trials were at low risk of bias in most domains but some were high risk for blinding, attrition bias, and selective reporting. Selection bias (allocation concealment) was generally unclear. The certainty of evidence was downgraded due to risk of bias and to imprecision (low numbers of women participating in the trials). Conflicts of interest on the part of trial authors, and the involvement of industry funders may also have had an impact on the certainty of the evidence. Most trials reported our primary outcome of incidence of mastitis but there were almost no data relating to adverse effects, breast pain, duration of breastfeeding, nipple damage, breast abscess or recurrence of mastitis. Probiotics versus placebo Probiotics may reduce the risk of mastitis more than placebo (risk ratio (RR) 0.51, 95% confidence interval (CI) 0.35 to 0.75; 2 trials; 399 women; low-certainty evidence). It is uncertain if probiotics reduce the risk of breast pain or nipple damage because the certainty of evidence is very low. Results for the biggest of these trials (639 women) are currently unavailable due to a contractual agreement between the probiotics supplier and the trialists. Adverse effects were reported in one trial, where no woman in either group experienced any adverse effects. Antibiotics versus placebo or usual care The risk of mastitis may be similar between antibiotics and usual care or placebo (RR 0.37, 95% CI 0.10 to 1.34; 3 trials; 429 women; low-certainty evidence). The risk of mastitis may be similar between antibiotics and fusidic acid ointment (RR 0.22, 95% CI 0.03 to 1.81; 1 trial; 36 women; low-certainty evidence) or mupirocin ointment (RR 0.44, 95% CI 0.05 to 3.89; 1 trial; 44 women; low-certainty evidence) but we are uncertain due to the wide CIs. None of the trials reported adverse effects. Topical treatments versus breastfeeding advice The risk of mastitis may be similar between fusidic acid ointment and breastfeeding advice (RR 0.77, 95% CI 0.27 to 2.22; 1 trial; 40 women; low-certainty evidence) and mupirocin ointment and breastfeeding advice (RR 0.39, 95% CI 0.12 to 1.35; 1 trial; 48 women; low-certainty evidence) but we are uncertain due to the wide CIs. One trial (42 women) compared topical treatments to each other. The risk of mastitis may be similar between fusidic acid and mupirocin (RR 0.51, 95% CI 0.13 to 2.00; low-certainty evidence) but we are uncertain due to the wide CIs. Adverse events were not reported. Specialist breastfeeding education versus usual care The risk of mastitis (RR 0.93, 95% CI 0.17 to 4.95; 1 trial; 203 women; low-certainty evidence) and breast pain (RR 0.93, 95% CI 0.36 to 2.37; 1 trial; 203 women; low-certainty evidence) may be similar but we are uncertain due to the wide CIs. Adverse events were not reported. Anti-secretory factor-inducing cereal versus standard cereal The risk of mastitis (RR 0.24, 95% CI 0.03 to 1.72; 1 trial; 29 women; low-certainty evidence) and recurrence of mastitis (RR 0.39, 95% CI 0.03 to 4.57; 1 trial; 7 women; low-certainty evidence) may be similar but we are uncertain due to the wide CIs. Adverse events were not reported. Acupoint massage versus routine care Acupoint massage probably reduces the risk of mastitis compared to routine care (RR 0.38, 95% CI 0.19 to 0.78;1 trial; 400 women; moderate-certainty evidence) and breast pain (RR 0.13, 95% CI 0.07 to 0.23; 1 trial; 400 women; moderate-certainty evidence). Adverse events were not reported. Breast massage and low frequency pulse treatment versus routine care Breast massage and low frequency pulse treatment may reduce risk of mastitis (RR 0.03, 95% CI 0.00 to 0.21; 1 trial; 300 women; low-certainty evidence). Adverse events were not reported. AUTHORS' CONCLUSIONS: There is some evidence that acupoint massage is probably better than routine care, probiotics may be better than placebo, and breast massage and low frequency pulse treatment may be better than routine care for preventing mastitis. However, it is important to note that we are aware of at least one large trial investigating probiotics whose results have not been made public, therefore, the evidence presented here is incomplete. The available evidence regarding other interventions, including breastfeeding education, pharmacological treatments and alternative therapies, suggests these may be little better than routine care for preventing mastitis but our conclusions are uncertain due to the low certainty of the evidence. Future trials should recruit sufficiently large numbers of women in order to detect clinically important differences between interventions and results of future trials should be made publicly available.

Bubble-positive expiratory pressure device and sputum clearance in bronchiectasis: A randomised cross-over study.

OBJECTIVES: The bubble-positive expiratory pressure (PEP) device may be used for sputum clearance in people with daily sputum production. However, this device has never been studied in people with bronchiectasis. Hence, the objective of this study was to compare the effect of bubble-PEP device, the active cycle of breathing technique (ACBT) and no intervention (control) on sputum clearance in people with bronchiectasis. METHODS: This was a prospective, randomised cross-over trial with concealed allocation, assessor blinding and intention-to-treat analysis. Adult participants with stable bronchiectasis and productive of sputum daily were recruited. Participants performed 30-min of bubble-PEP, ACBT or control in random order whilst sitting, followed by 60-min of quiet sitting, on three separate days at the same time within a 10-day period. Primary outcome measure was wet weight of expectorated sputum during 30-min intervention, 60-min post intervention and total wet weight (30 min plus 60 min). RESULTS: Thirty-five-participants (11 males, mean [standard deviation] age 75 [8] years, forced expiratory volume in 1 s 72 [20] % predicted) were recruited and 34 completed the study. There was no significant difference in sputum wet weight between bubble-PEP and ACBT during 30-min intervention (mean difference [95% confidence interval]) -0.59 g [-1.37, 0.19] and total wet weight (0.74 g [-0.54, 2.02]). Sputum wet weight was significantly greater in bubble-PEP than ACBT at 60-min post intervention (1.33 g [0.19, 2.47]). CONCLUSION: Sputum wet weight was significantly greater with bubble-PEP than control at all time periods, and greater than ACBT at 60-min-post. Bubble-PEP could be considered an alternative sputum clearance technique to ACBT.

Tubing internal diameter affects the pressures and oscillation frequencies generated by the therapist-made bubble-positive expiratory pressure device.

Objectives: To determine the positive expiratory pressures (PEP) and oscillation frequencies generated in the therapist-made-bubble-PEP device using tubing with different internal diameters (IDs). Design: Bench-top experimental study. Therapist-made-bubble-PEP device with a 10 cm column height of water, tubing length of 30 cm with distal end of the tubing resting 3 cm from base of container. Tubing with 2, 4, 5, 7, 8, and 10 mm IDs were tested with flows of 5, 10, 15, 20, and 25 L/min. A pressure transducer measured the pressures and oscillation frequencies. Data were captured with PhysioDAQxs© software and analyzed with Breathalyser© software. Results: Therapist-made-bubble-PEP device with: (1) 2 mm ID tubing with 5 and 10 L/min flows produced mean(SD) PEP of 20.1(0.2) and 41.8(0.5)cmH2O, respectively, oscillation frequencies of 15-19 Hz; (2) 4 mm ID tubing with 5 and 25 L/min flows produced PEP of 12.5(0.2) and 41.5(0.3)cmH2O, oscillations of 14-18 Hz; (3) 5 mm ID tubing with 5 and 25 L/min flows produced PEP of 10.9(0.1) and 15.8(0.1)cmH2O, oscillations of 17-18 Hz; (4) 7 mm ID tubing with 5 and 25 L/min flows produced PEP of 10.7(0.0) and 12.7(0.2)cmH2O, oscillations of 14-17 Hz; (5) 8 mm ID tubing with 5 and 25 L/min flows produced PEP of 10.5(0.0) and 11.4(0.0)cmH2O, oscillations of 14-18 Hz; and (6) 10 mm ID tubing with 5 and 25 L/min flows produced PEP of 10.4(0.1) and 10.8(0.2)cmH2O, oscillations of 13-17 Hz. Conclusions: Therapist-made-bubble-PEP device with tubing of 10 mm ID generated the most stable PEP in relation to water height (10 cm) irrespective of flow compared to tubing with ID of 2, 4, 5, 7, and 8 mm. The oscillation frequencies generated at all flows and tubing IDs were between 13 and 19 Hz.

A GIS approach to sediment displacement in mixed sand and gravel beach environments.

Mixed sand and gravel beaches pose special management issues as they are morphologically distinct from either pure sand or shingle beaches. On the mixed sand and gravel beaches of the Canterbury Bight, New Zealand, displacement of sediments operates within a two-part sediment transport system. The large sediments are retained in the beaches, while the fine sand, silt, and mud are transported offshore to the continental shelf. While the susceptibility of sediments to size-reduction is dependent on the textural mixture of sediments, the actual size-reduction takes place during sediment transport, or displacement, in the active surf zone of the beach. The authors outline a method that incorporates the sediment reduction susceptibility of beach sediments from the textural mixture, twenty years of wave-hindcast data, and sediment tracer experiments to model sediment displacement in mixed sand and gravel beach environments of the Canterbury Bight. Results show that the textural mix of the sediments influences not only the rate of loss to size-reduction but also the time taken for sediment to be transported along a beach continuum within the surf zone. The authors modelled time-frames to achieve three target percentages of sediment displacement: (1) ten percent, (2) fifty percent, and (3) a range of zero to one hundred percent. Ten percent displacement of sediments was predicted to take between four and eighty-eight weeks, fifty percent displacement between one and sixteen years, and a hundred percent displacement up to two-hundred and thirty years, depending on the textural composition of sediments along the coast based on the actual wave action occurring along this coastline.

Non-invasive ventilation versus oxygen therapy in cystic fibrosis: A 12-month randomized trial.

BACKGROUND AND OBJECTIVE: No published studies have examined the long-term effects of non-invasive ventilation (NIV) in cystic fibrosis (CF). Our primary aim was to determine if adults with CF and sleep desaturation were less likely to develop hypercapnia with NIV ± O2 compared to low-flow oxygen therapy (LFO2 ) or meet the criteria for failure of therapy over 12 months. We studied event-free survival, hospitalizations, lung function, arterial blood gases (ABG), sleep quality and health-related quality of life. METHODS: A prospective, randomized, parallel group study in adult patients with CF and sleep desaturation was conducted, comparing 12 months of NIV ± O2 to LFO2 . Event-free survival was defined as participants without events. Events included: failure of therapy with PaCO2 > 60 mm Hg, or increase in PaCO2 > 10 mm Hg from baseline, increases in TcCO2 > 10 mm Hg, lung transplantation or death. Outcomes were measured at baseline, 3, 6 and 12 months, including lung function, ABG, Pittsburgh Sleep Quality Inventory (PSQI), SF36 and hospitalizations. RESULTS: A total of 29 patients were randomized to NIV ± O2 (n = 14) or LFO2 (n = 15) therapy for 12 months. Of the 29 patients, 18 met the criteria for event-free survival over 12 months. NIV ± O2 group had 33% (95% CI: 5-58%) and 46% (95% CI: 10-68%) more event-free survival at 3 and 12 months than LFO2 group. No statistically significant differences were seen in spirometry, ABG, questionnaires or hospitalizations. CONCLUSION: NIV ± O2 during sleep increases event-free survival over 12 months in adults with CF. Further studies are required to determine which subgroups benefit the most from NIV.

Infective endocarditis: a retrospective cohort study.

BACKGROUND: Infective endocarditis (IE) is a potentially life-threatening infection of the heart's endocardial surface. Despite advances in the diagnosis and management of IE, morbidity and mortality remain high. AIM: To characterize the demographics, bacteriology and outcomes of IE cases presenting to an Irish tertiary referral centre. DESIGN: Retrospective cohort study. METHODS: Patients were identified using Hospital Inpatient Enquiry and Clinical Microbiology inpatient consult data, from January 2005 to January 2014. Patients were diagnosed with IE using Modified Duke Criteria. Standard Bayesian statistics were employed for analysis and cases were compared to contemporary international registries. RESULTS: Two hundred and two patients were diagnosed with IE during this period. Mean age 54 years. Of these, 136 (67%) were native valve endocarditis (NVE), 50 (25%) were prosthetic valve endocarditis (PVE) and 22 (11%) were cardiovascular implantable electronic device-associated endocarditis. Culprit organism was identified in 176 (87.1%) cases and Staphylococcal species were the most common (57.5%). Fifty-nine per cent of NVE required surgery compared to 66% of PVE. Mean mortality rate was 17.3%, with NVE being the lowest (12.5%) and PVE the highest (32%). Increasing age was also associated with increased mortality. Fifty-three (26.2%) patients had embolic complications. CONCLUSIONS: This Irish cohort exhibited first-world demographic patterns comparable to those published in contemporary international literature. PVE required surgery more often and was associated with higher rates of mortality than NVE. Embolic complications were relatively common and represent important sequelae, especially in the intravenous drug user population. It is also pertinent to aggressively treat older cohorts as they were associated with increased mortality.

Comprehensive blood group antigen profile predictions for Western Desert Indigenous Australians from whole exome sequence data.

BACKGROUND: The distribution of RBC antigens, which define blood group types, differs among populations. In contrast to many world populations, blood group profiles for Indigenous Australians have not been well studied. As it is now possible to predict comprehensive blood group antigen profiles from genomic data sets, we aimed to apply this for Indigenous Australians and to provide a comparison to other major world populations. STUDY DESIGN AND METHODS: Whole exome sequence data for 72 Western Desert Indigenous Australians was provided by the Telethon Kids Institute. Variants (against hg19) were annotated using computer software (ANNOVAR, Qiagen Bioinformatics) and filtered to include only variants in genes for 36 blood group systems, and the transcription factors KLF1 and GATA1. The RHCE*C allele and RHD zygosity were identified by copy number variant analysis of sequence alignments. The impact of missense variants was investigated in silico using a meta-predictor of disease-causing variants (Meta-SNP). RESULTS: For 21 blood group systems the predicted blood group antigen frequencies were comparable to those for other major world populations. For 13 systems, interesting points of contrast were identified. Furthermore, we identified 12 novel variants, one novel D allele, and four rare variants with potential clinical significance. CONCLUSION: This is the first systematic assessment of genomic data to elucidate blood group antigen profiles for Indigenous Australians who are linguistically and culturally diverse. Our study paves the way to understanding the geographic distribution of blood group variants in different Indigenous groups and the associated RBC phenotypes. This in turn is expected to guide transfusion practice for Indigenous individuals.

Effect of Continuous Local Anesthetic in Post-Cardiac Surgery Patients: A Systematic Review.

Objective: The purpose of this review was to determine the effect of CLA infusion post cardiac surgery on pain, time to ambulation, severe adverse events, patient satisfaction, time to extubation, length of stay in the intensive care unit and in the hospital, total narcotic consumption, and pulmonary function. Design: Systematic review with meta-analysis (PROSPERO CRD42014010188). Methods: We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Allied and Complementary Medicine (AMED); and PsycINFO; as well as hand-searching cardiothoracic surgery and anesthetic journals and meeting abstracts. Results: Ten eligible trials with a total of 546 participants were identified. Meta-analyses showed that CLA infusion significantly reduced the total mean visual analog pain score at 72 hours (mean difference [MD] = -14.31 mm, 95% confidence interval [CI] = -25.59 to -3.03); time to ambulation (MD = -2.81 hours, 95% CI = -5.23 to -0.4); morphine requirement (MD = -10.19 mg, 95% CI = -11.80 to -8.58) but did not reduce time to ambulate to chair (MD = -1.65 hours, 95% CI = -4.04 to 0.74); time to extubation (MD = -0.18 hours, 95% CI = -1.24 to 0.89); length of ICU stay (MD = 0.9 hours, 95% CI = -2.96 to 4.75); and hospital length of stay (MD = -0.59 days, 95% CI = -1.24 to 0.07). There were insufficient data to perform a meta-analysis on severe adverse events, patient satisfaction, or pulmonary function. Conclusions: CLA infusion after cardiac surgery reduces pain score at 72 hours, shortens time to ambulation, and reduces morphine consumption at 48 hours.

Early and mid-term outcomes after transcatheter aortic valve implantation (TAVI) in Ireland.

BACKGROUND: TAVI is a percutaneous approach to aortic valve replacement in high surgical risk patients deemed inoperable. AIM: To evaluate the early and mid-term outcomes for an Irish TAVI cohort over a six-year period at St James's Hospital and Blackrock Clinic, Dublin, Ireland. RESULTS: In total 147 patients, 56% male with an average age of 82 underwent TAVI between December 2008 and December 2014. Thirty day, one year and two year survival was 90.5%, 83% and 71% respectively. Major vascular complications and renal failure were the biggest predictors of mortality at 30 days (p = 0.02). We observed a pacing rate of 13.5%, the majority in patients who had Medtronic Corevalve implants (p < 0.05). With increasing procedural experience there was a reduction in length of stay from 10 days to 7.5 days. CONCLUSION: This review, the first of its kind in Ireland showed favorable rates of 30 day and one year and two year survival post TAVI with procedural success and complication rates similar to international registry data.

Does continuous infusion of local anaesthesia improve pain control and walking distance after coronary artery bypass graft surgery? A randomised controlled trial.

OBJECTIVES: To evaluate the effects of continuous infusion of ropivacaine compared to sham infusion or usual care on pain scores before and after physiotherapy treatment, distance walked and time to discharge from physiotherapy, after coronary artery bypass graft (CABG) surgery. DESIGN: Prospective, randomised, double blind controlled trial. SETTING AND PARTICIPANTS: Seventy-five participants who underwent CABG surgery with left internal mammary artery grafts were allocated, to the ropivacaine group (n=26), the sham group (n=25), or usual care group (n=24). Participants in the ropivacaine group received 0.5% ropivacaine and participants in the sham group received normal saline, both as continuous infusions via two parasternally tunnelled catheters for 96hours continuously. The usual care group did not receive a device. All groups had patient-controlled analgesia and/or oral analgesia. RESULTS: Seventy-two participants completed the study. There was no significant between-group differences in pain scores, distance walked on any post operative day (POD) or number of participants discharged from physiotherapy by POD 4. For the group as a whole there was a significant linear decrease in pain score from mean (SD) 42 (24) mm on POD1 to 15 (16) mm on POD4 (p<0.001), (MD 27mm, 95% CI 22 to 32) and walking distance increased from 1 (5) m on POD1 to 183 (239) m on POD4 (p<0.001) MD 181m, 95% CI 126 to 236). CONCLUSION: Infusion of ropivacaine post CABG surgery was unable to reduce pain, increase distance walked or reduce time to physiotherapy discharge compared to sham or usual care. Trial registration number ACTRN12612001243808.

Comparison of the BBL mycobacteria growth indicator tube, the BACTEC 12B, and solid media for the isolation of Mycobacterium bovis.

We compared different methods for their ability to isolate Mycobacterium bovis from tissue samples from animals with lesions resembling bovine tuberculosis. In the first trial, M. bovis was isolated from 86 of 200 tissue samples that were cultured using 2 liquid media, BACTEC 12B and BBL mycobacteria growth indicator tube (MGIT), and a solid medium, Middlebrook 7H11 supplemented with pyruvate (7H11P). M. bovis was isolated from 2 samples with MGIT but not BACTEC 12B. M. bovis was isolated from 9 samples with BACTEC but not MGIT; these 9 samples came from the North Canterbury/Marlborough region of New Zealand. The proportion of tissues from which M. bovis was isolated with BACTEC 12B or MGIT and the mean time for isolation was different for samples from the North Canterbury/Marlborough region but not the rest of New Zealand. In the second trial, M. bovis was isolated from 401 of 1,033 tissues that were cultured using MGIT, Middlebrook 7H9 broth, or solid 7H11P. The proportion of isolates of M. bovis and the mean time for their isolation with MGIT was different for the North Canterbury/Marlborough and the rest of New Zealand. The reason for this difference was not determined but may be related to the genotypes present in this region. Genotyping using variable number tandem repeats (VNTRs) of 197 isolates of M. bovis revealed that the 44 isolates from North Canterbury/Marlborough were represented by 2 closely related VNTR types that were not found in 153 isolates from the remainder of New Zealand.

Pressures and Oscillation Frequencies Generated by Bubble-Positive Expiratory Pressure Devices.

BACKGROUND: Positive expiratory pressure (PEP) devices are used to assist with airway clearance. Little is known about the therapist-made or commercially available bubble-PEP devices. The aim of this study was to determine the end-expiratory pressures (cm H2O) and oscillation frequencies (Hz) generated when a range of flows were applied to the therapist-made bubble-PEP devices (Bubble-PEP-3cm and Bubble-PEP-0cm) and commercial bubble-PEP devices (AguaPEP, Hydrapep, and Therabubble). METHODS: This was a bench-top experimental study using a compressed air source, flow rotameter (flows of 5, 10, 15, 20, and 25 L/min), and pressure transducer. Data were collected using a data acquisition device with PhysioDAQxs software and analyzed with Breathalyser software to determine the pressures and oscillation frequencies generated by 5 bubble-PEP devices. Each flow was constant for a 30-s measurement period, and measurements were repeated in triplicate. The 5 devices were: a therapist-made Bubble-PEP-3cm device (filled with 13 cm of water, tubing resting 3 cm from the base of the container); the therapist-made Bubble-PEP-0cm (filled with 10 cm of water, tubing resting at the base of the container); and the AguaPEP, Hydrapep, and Therabubble devices with water to the 10 cm mark on the containers. RESULTS: Flows of 5-25 L/min produced the following mean ± SD PEP and oscillation frequencies (Hz): the Bubble-PEP-3cm produced PEP of 10.4 ± 0.14 to 10.8 ± 0.24 cm H2O, oscillations between 13 and 17 Hz; the Bubble-PEP-0cm produced PEP of 10.9 ± 0.01 to 12.9 ± 0.08 cm H2O, oscillations between 12 and 14 Hz; the AguaPEP produced PEP from 9.7 ± 0.02 to 11.5 ± 0.02 cm H2O, oscillations between 11 and 17 Hz; the Hydrapep produced PEP of 9.6 ± 0.35 to 10.7 ± 0.39 cm H2O, oscillations between 14 and 17 Hz; and the Therabubble produced PEP from 8.6 ± 0.01 to 12.8 ± 0.03 cm H2O, oscillations between 14 and 17 Hz. CONCLUSIONS: Bubble-PEP-3cm maintained the most stable pressure throughout the range of flows tested. All devices investigated produced similar oscillation frequencies.