Transventricular Cardioscopic Release of a Trapped Prosthetic Mitral Valve Leaflet.

Trapped prosthetic valve leaflets are a rare but challenging complication. A 68-year-old male patient had previously undergone redo aortic valve replacement. Postoperatively, he decompensated with severe mitral regurgitation, requiring extracorporeal membrane oxygenation and a salvage mitral valve replacement via right thoracotomy with very difficult access. This procedure was complicated by a trapped valve leaflet. He recovered well initially but presented 2 years later with worsening heart failure due to mitral stenosis and rising pulmonary artery pressures. Due to the high risk of sternotomy and right thoracotomy, a transventricular cardioscopic release of the trapped mitral valve leaflet was undertaken by left minithoracotomy. The procedure was successful, and the patient was discharged home on day 12. This novel minimally invasive approach, which does not require myocardial preservation, is ideal for high-risk patients with this rare complication and has not previously been described. We hope that by sharing our experience, others will consider this innovative approach.

A human model of bilateral pulmonary vein sampling to assess the effects of one-lung ventilation on neutrophil function.

BACKGROUND: Neutrophil activation drives lung complications after cardiopulmonary bypass (CPB). Evidence suggests the healthy, ventilated lung may beneficially re-condition pro-inflammatory neutrophils. However, evidence in humans is lacking, due to a paucity of good models. CPB with simultaneous central venous and bilateral pulmonary vein sampling provides an opportunity to model effects of one-lung ventilation. The study's primary objectives were to establish a model of intra-operative, bilateral pulmonary vein sampling and to determine whether neutrophil function differed after passing through inflated or deflated lungs. METHODS: Seventeen patients having "on pump" coronary artery bypass grafting (CABG) with one-lung ventilation (in two cohorts with tidal volume 2ml kg-1 and FiO2 0.21, or tidal volume 4 ml kg-1 and FiO2 0.5 respectively) were recruited. Cohort 1 consisted of 9 patients (7 male, median age 62.0 years) and Cohort 2 consisted of 8 male patients (median age 65.5 years). Recruitment was via prospective screening of scheduled elective and non-elective CABG procedures with cardiopulmonary bypass. Each patient had five blood samples taken-central venous blood pre-operatively; central venous blood pre-CPB; central venous blood post-CPB; pulmonary venous blood draining the ventilated lung post-CPB; and pulmonary venous blood draining the deflated lung post-CPB. Neutrophil phagocytosis and priming status were quantified. Plasma cytokines were measured. RESULTS: Phagocytosis and priming were not significantly different in neutrophils returning from the ventilated lung as compared to the non-ventilated lung. Plasma IL-6, IL-8 and IL-10 were significantly elevated by CPB. CONCLUSIONS: The intra-operative, bilateral pulmonary vein sampling model provides unique opportunities to assess biological effects of interventions to one lung, with the other lung acting as an internal control. Single-lung ventilation during CPB had no significant effects on neutrophil function.

Surgical Performance Anxiety and Wellbeing Among Surgeons: A Cross-sectional Study in the United Kingdom.

OBJECTIVE: This national cross-sectional study aims to establish the prevalence and potential impact of performance anxiety among surgeons and investigate its association with psychological traits and wellbeing. SUMMARY AND BACKGROUND DATA: Despite a growing awareness that human factors, non-technical skills and wellbeing in healthcare affect patient outcomes, an area that has remained unexplored is surgical performance anxiety (SPA). METHODS: A prospectively registered, cross-sectional study using mixed methods was conducted across the United Kingdom. Data captured included demographics, surgical specialty, trait anxiety, trait perfectionism, SPA, and surgical perfectionism scores. Wellbeing was assessed using The Short Warwick-Edinburgh Mental Wellbeing Scale, whereas qualitative data were collected regarding surgeons' experiences of SPA. RESULTS: A total of 631 responses were collected. Mean age was 41·2 years and mean surgical experience 15·3 years. A total of 62% were male and 52% of consultant/attending grade. A total of 100% felt that SPA affected surgeons, with 87% having experienced it themselves. A total of 65% reported SPA negatively impacted surgical performance and 96% felt SPA negatively impacted surgeons' wellbeing. Male surgeons reported significantly better wellbeing than female surgeons. Surgeons with SPA reported significantly worse wellbeing compared with surgeons who did not experience SPA. Surgeons in general experienced significantly lower mental wellbeing compared with population norms. Thematic analysis highlighted a reticence to share SPA openly and need for cultural change. CONCLUSIONS: Surgical performance anxiety is a very common and significant challenge among surgeons across all specialties at all levels of experience in the United Kingdom. It is perceived by surgeons to affect surgical performance adversely and is associated with worse psychological wellbeing. A more open culture of sharing and acknowledgment has been identified to be beneficial.

Using existing technology better: Improving outcomes with the HeartWare left ventricular assist device.

BACKGROUND: The HeartWare left ventricular assist device has been in use for over 12 years. We sought to determine how outcomes at our centre have improved over time. METHODS: Review of electronic hospital records at the Freeman Hospital, Newcastle upon Tyne, United Kingdom. RESULTS: A total of 255 first time adult implants were divided into 2 eras: Era 1: 2009-2015 (N = 154) and Era 2: 2016-2020 (N = 101). We prospectively aimed to avoid higher risk Intermacs Classifications in Era 2, which resulted in significant changes in Intermacs class to lower risk in Era 2 (P < 0.001). There was a significant improvement in survival in Era 2, with 1 year survival increasing from 70 to 80% (P < 0.05). This was particularly associated with lower 30 day mortality in Era 2 (1.7 ± 2.3 vs 15.5 ± 7%, P < 0.005). This was associated with better right ventricular function in Era 2, and there was a trend to more temporary right ventricular assist devices used in Era 2 (28 ± 13 vs 12 ± 14%, P = 0.06). Deaths from intracranial haemorrhage, sepsis and right heart failure were unchanged between eras, though there was a trend towards less deaths in Era 2 from combined thromboses deaths (stroke and device thrombosis; 3.3 ± 5.4 vs 11.1 ± 7.4%, P = 0.07). CONCLUSIONS: Better patient selection in association with more use of temporary right ventricular assist support has resulted in a significant improvement in survival. Intracranial haemorrhage, sepsis and right heart failure remain significant problems.

Workplace assessment in crisis? The way forward.

A recent Royal College of Physicians' study on assessment raises serious questions for workplace assessment. To address these, a system is recommended that bridges the gap from competence to performance and integrates supervised learning events (SLEs) that are formative in purpose with summative assessment of performance by entrustable professional activities (EPAs).

Acid environments affect biofilm formation and gene expression in isolates of Salmonella enterica Typhimurium DT104.

The aim of this study was to examine the survival and potential virulence of biofilm-forming Salmonella Typhimurium DT104 under mild acid conditions. Salmonella Typhimurium DT104 employs an acid tolerance response (ATR) allowing it to adapt to acidic environments. The threat that these acid adapted cells pose to food safety could be enhanced if they also produce biofilms in acidic conditions. The cells were acid-adapted by culturing them in 1% glucose and their ability to form biofilms on stainless steel and on the surface of Luria Bertani (LB) broth at pH7 and pH5 was examined. Plate counts were performed to examine cell survival. RNA was isolated from cells to examine changes in the expression of genes associated with virulence, invasion, biofilm formation and global gene regulation in response to acid stress. Of the 4 isolates that were examined only one (1481) that produced a rigid biofilm in LB broth at pH7 also formed this same structure at pH5. This indicated that the lactic acid severely impeded the biofilm producing capabilities of the other isolates examined under these conditions. Isolate 1481 also had higher expression of genes associated with virulence (hilA) and invasion (invA) with a 24.34-fold and 13.68-fold increase in relative gene expression respectively at pH5 compared to pH7. Although genes associated with biofilm formation had increased expression in response to acid stress for all the isolates this only resulted in the formation of a biofilm by isolate 1481. This suggests that in addition to the range of genes associated with biofilm production at neutral pH, there are genes whose protein products specifically aid in biofilm production in acidic environments. Furthermore, it highlights the potential for the use of lactic acid for the inhibition of Salmonella biofilms.

Management issues during HeartWare left ventricular assist device implantation and the role of transesophageal echocardiography.

Left ventricular assist devices (LVAD) are increasingly used for mechanical circulatory support of patients with severe heart failure, primarily as a bridge to heart transplantation. Transesophageal echocardiography (TEE) plays a major role in the clinical decision making during insertion of the devices and in the post-operative management of these patients. The detection of structural and device-related mechanical abnormalities is critical for optimal functioning of assist device. In this review article, we describe the usefulness of TEE for optimal perioperative management of patients presenting for HeartWare LVAD insertion.

Evidence of metabolic switching and implications for food safety from the phenome(s) of Salmonella enterica serovar Typhimurium DT104 cultured at selected points across the pork production food chain.

Salmonella enterica serovar Typhimurium DT104 is a recognized food-borne pathogen that displays a multidrug-resistant phenotype and that is associated with systemic infections. At one extreme of the food chain, this bacterium can infect humans, limiting the treatment options available and thereby contributing to increased morbidity and mortality. Although the antibiotic resistance profile is well defined, little is known about other phenotypes that may be expressed by this pathogen at key points across the pork production food chain. In this study, 172 Salmonella enterica serovar Typhimurium DT104/DT104b isolated from an extensive "farm-to-fork" surveillance study, focusing on the pork food chain, were characterized in detail. Isolates were cultured from environmental, processing, retail, and clinical sources, and the study focused on phenotypes that may have contributed to persistence/survival in these different niches. Molecular subtypes, along with antibiotic resistance profiles, tolerance to biocides, motility, and biofilm formation, were determined. As a basis for human infection, acid survival and the ability to utilize a range of energy sources and to adhere to and/or invade Caco-2 cells were also studied. Comparative alterations to biocide tolerance were observed in isolates from retail. l-Tartaric acid and d-mannose-1-phosphate induced the formation of biofilms in a preselected subset of strains, independent of their origin. All clinical isolates were motile and demonstrated an enhanced ability to survive in acidic conditions. Our data report on a diverse phenotype, expressed by S. Typhimurium isolates cultured from the pork production food chain. Extending our understanding of the means by which this pathogen adapts to environmental niches along the "farm-to-fork" continuum will facilitate the protection of vulnerable consumers through targeted improvements in food safety measures.

Microbiological study of biofilm formation in isolates of Salmonella enterica Typhimurium DT104 and DT104b cultured from the modern pork chain.

The purpose of this study was to characterise 172 Salmonella Typhimurium isolates taken from the pork chain for their biofilm forming abilities and to analyse their potential to survive on food processing surfaces. Many Salmonella have the ability to form biofilms. These natural structures, elaborated by bacteria are important in food production because their formation contributes to bacterial survival. Adherent bacterial cells are more resilient to displacement strategies including physical and chemical procedures as a consequence of their altered more resistant phenotype. By improving our understanding of the nature of biofilms, this data could positively contribute to the development and implementation of eradication strategies. In this study, Salmonella Typhimurium DT104 and DT104b were investigated for their ability to form biofilms on a range of different surfaces under defined environmental growth conditions. Phenotypic characterisation involved examining colony morphology on indicator agars, assessing their ability to survive chlorine-based challenges and investigating their ability to attach to stainless steel and to plastic surfaces. All bacterial isolates were investigated for the presence of Salmonella genomic island I (SGI1) which is thought to enhance efficient biofilm formation. It was found that the majority of strains possess biofilm forming capabilities but successful attachment is highly dependent on the surface on which the biofilm is forming. The strains readily attached to stainless steel and plastic surfaces and survived high chlorine concentrations. Molecular and phenotypic comparisons of strong and weak biofilm forming strains indicate that biofilm development is not solely dependent on the acquirement of SGI1.

Onset of remission and relapse in depression: testing operational criteria through course description in a second Dublin cohort of first-admission participants.

BACKGROUND: This paper extends previous work describing course in depression using a recommended operational model that defines remission onset and relapse. We test whether a similar course pattern would emerge using this model in a new cohort of depressed participants. METHODS: We recruited a cohort of 86 participants, first-time inpatients, with DSM-IV major depression. Outcome was assessed prospectively over a 13-month minimum follow-up period. Remission onset was defined as a Ham-D score <8 for two consecutive weeks; relapse as a Ham-D score >16 for two consecutive weeks and meeting DSM-IV criteria for major depressive disorder. RESULTS: The cumulative probability of remission onset was 0.62 (SE=0.05) and 0.80 (SE=0.05) at 3 and 6 months following study entry. The relapse risk was 0.28 (SE=0.05) at 6 months post remission onset; 53% of those relapsing did so in the first 2 months post remission onset. Predictors of longer times to remission onset included: longer illness length, higher anxiety scores and unemployment; higher anxiety scores predicted relapse. The course pattern is similar to that reported previously. LIMITATIONS: These findings apply to inpatients only. Course was not rated blind to all of the participants' baseline data. CONCLUSIONS: Defining remission onset and relapse using this model is associated with a replicable course pattern. A singular clinical advantage of the model is the identification of those participants at highest risk of relapse 2 months post remission onset.