Association between HbA1c and deep sternal wound infection after coronary artery bypass: a systematic review and meta-analysis.

BACKGROUND: Deep sternal wound infection (DSWI) constitutes a serious complication after coronary artery bypass grafting (CABG) surgery. The aim of this study is to evaluate the dose-response relationship between glycated hemoglobin (HbA1c) level and the risk of DSWI after CABG. METHODS: PubMed, Scopus, and Cochrane Library databases were searched to identify potentially relevant articles. According to rigorous inclusion and exclusion criteria, fourteen studies including 15,570 patients were enrolled in our meta-analysis. Odds ratio (OR) with 95% confidence intervals (CIs) was used as the summary statistic. The robust-error meta-regression model was used to synthesize the dose-response relationship. RESULTS: Our meta-analysis shows that among patients undergoing CABG, preoperative elevated HbA1c was associated with the risk of developing DSWI (OR = 2.67, 95% CI 2.00-3.58) but with low prognostic accuracy (diagnostic OR = 2.70, 95% CI 1.96-3.73; area under the curve = 0.66, 95% CI 0.62-0.70) for predicting postoperative DSWI. Subgroup analyses showed the relationship became nonsignificant in patients without diabetes and studies adopting lower HbA1c thresholds. Dose-response analysis showed a significant nonlinear (p = 0.03) relationship between HbA1c and DSWI, with a significantly increased risk of DSWI when HbA1c was > 5.7%. CONCLUSIONS: An elevated HbA1c level of > 5.7% was related to a higher risk of developing DSWI after CABG, and the risk increased as the HbA1c level grew. The association between HbA1c and DSWI was nonsignificant among nondiabetic patients while significant among diabetic patients.

Impact of restrictive red blood cell transfusion strategy on thrombosis-related events: A meta-analysis and systematic review.

BACKGROUND AND OBJECTIVES: There is an ongoing controversy regarding the risks of restrictive and liberal red blood cell (RBC) transfusion strategies. This meta-analysis assessed whether transfusion at a lower threshold was superior to transfusion at a higher threshold, with regard to thrombosis-related events, that is, whether these outcomes can benefit from a restrictive transfusion strategy is debated. MATERIALS AND METHODS: We searched PubMed, Cochrane Central Register of Controlled Trials and Scopus from inception up to 31 July 2021. We included randomized controlled trials (RCTs) in any clinical setting that evaluated the effects of restrictive versus liberal RBC transfusion in adults. We used random-effects models to calculate the risk ratios (RRs) and 95% confidence intervals (CIs) based on pooled data. RESULTS: Thirty RCTs involving 17,334 participants were included. The pooled RR for thromboembolic events was 0.65 (95% CI 0.44-0.94; p = 0.020; I2  = 0.0%, very low-quality evidence), favouring the restrictive strategy. There were no significant differences in cerebrovascular accidents (RR = 0.83; 95% CI 0.64-1.09; p = 0.180; I2  = 0.0%, very low-quality evidence) or myocardial infarction (RR = 1.05; 95% CI 0.87-1.26; p = 0.620; I2  = 0.0%, low-quality evidence). Subgroup analyses showed that a restrictive (relative to liberal) strategy reduced (1) thromboembolic events in RCTs conducted in North America and (2) myocardial infarctions in the subgroup of RCTs where the restrictive transfusion threshold was 7 g/dl but not in the 8 g/dl subgroup (with a liberal transfusion threshold of 10 g/dl in both subgroups). CONCLUSIONS: A restrictive (relative to liberal) transfusion strategy may be effective in reducing venous thrombosis but not arterial thrombosis.

The moderating effect of solar radiation on the association between human mobility and COVID-19 infection in Europe.

The novel coronavirus disease 2019 (COVID-19) has caused a global pandemic. Some studies have suggested a negative association between sunlight intensity and COVID-19 infection, alluding to the belief that it might be safe to go out on sunny days. This paper examined whether solar radiation mitigated the association between human mobility and COVID-19 infection in Europe using a dynamic panel data model to investigate the effect of human mobility, solar radiation, and their interaction on COVID-19 infection. The results revealed that outgoing mobility was positively correlated and solar radiation was negatively correlated with COVID-19 infection at lag levels of 1, 2, and 3 weeks. The coefficients of the interaction items indicated that solar radiation negatively moderated the relationship between outgoing mobility and the number of daily new confirmed cases at 2- and 3-week lag levels. However, the moderating effect was limited and unable to eliminate the positive effect of outgoing mobility on COVID-19 infection. Thus, these results suggested that solar radiation only weakly mitigated the relationship between human mobility and COVID-19 infection, providing policy implications that mobility should still be restricted on sunny days during the COVID-19 pandemic.

A rare case of ectopic retrosternal goiter.

It is important for the clinician to be familiar with interpreting a variety of radiological modalities that provide vital information that will aid in the preoperative planning, counseling, and subsequent management of patients with retrosternal goiter.

Effect of Renin-Angiotensin System Inhibitors on Acute Kidney Injury Among Patients Undergoing Cardiac Surgery: A Review and Meta-Analysis.

Acute kidney injury (AKI) is a frequent complication of cardiac surgery, which can lead to higher mortality and long-term renal function impairment. The effect of perioperative renin-angiotensin system inhibitors (RASi) therapy on AKI incidence in patients undergoing cardiac surgery remains controversial. We reviewed related studies in PubMed, Scopus, and Cochrane Library from inception to February 2020. Two randomized controlled trials and 21 cohort studies were included in the meta-analysis, involving 76,321 participants. The pooled odds ratio and 95% confidence interval were calculated using the DerSimonian and Laird random-effects model. The results showed no significant association between perioperative RASi therapy and postoperative AKI in patients undergoing cardiac surgery. We highlighted the limitations of existing studies and called for well-designed large-scale randomized controlled trials to verify the conclusion.

Validation of prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among cardiac-, thoracic-, and vascular-surgery patients admitted to a cardiothoracic intensive care unit.

SEPSIS-3 DEFINITION: Sepsis is defined as life-threatening organ dysfunction due to a dysregulated host response to infection. The clinical criteria of sepsis include organ dysfunction, which is defined as an increase of two points or more on the sequential organ failure assessment (SOFA). For patients with infection, an increase of 2 SOFA points yields an overall mortality rate of 10%. Patients with suspected infection who are likely to have a prolonged intensive care unit (ICU) stay or to have in-hospital mortality can be promptly identified at the bedside with a quick SOFA (qSOFA) score of 2 or higher. IMPORTANCE: The sepsis-3 criteria have emphasized the value of a change of two or more points on the SOFA, introduced the qSOFA, and removed the systemic inflammatory response syndrome (SIRS) criteria from the sepsis definition. OBJECTIVE: To externally validate and assess the discriminatory capacities of an increase in the SOFA score by two or more points, the presence of two or more SIRS criteria, or a qSOFA score of 2 or more points for outcomes in 5109 patients, the vast majority of whom were postcardiac surgery patients who were admitted to a Cardiothoracic Surgical ICU in Singapore. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort analysis of 5109 patients with an infection-related primary admission diagnosis in the cardiothoracic intensive care unit (CTICU) at the National University Hospital (NUH) in Singapore from 2010 to 2016. EXPOSURES: The SOFA, qSOFA, and SIRS criteria were applied to the data representing the worst condition within 24 hours of ICU admission. MAIN OUTCOMES AND MEASURES: The primary outcome was in-hospital mortality. Discrimination was assessed using the area under the receiver operating characteristic curve (AUROC). RESULTS: In 5109 patients, the average mortality of patients with an increase in the SOFA scores of less than 2 points was 3.5% (n = 64), and it was 6% (n = 199) for those with an increase in the SOFA scores of 2 or more points. The mortality of patients with an increase in the qSOFA scores of less than 2 points was 2.6% (n = 7), and it was 5.3% (n = 256) for those with an increase in the qSOFA scores of 2 or more points. The mortality of patients with an increase in the SIRS criteria of less than 2 points was 3.6% (n = 30), and it was 5.4% (n = 233) for those with an increase in the SIRS criteria of 2 or more points. The AUROC of in-hospital mortality of patients with an increase in the SOFA, qSOFA, and SIRS criteria of 2 or more points was 0.96, 0.95, and 0.95, respectively. CONCLUSIONS AND RELEVANCE: In adults with suspected infection admitted to the CTICU in NUH, the change in in-hospital mortality between patients with an increase in SOFA scores of less than 2 and those with an increase of 2 or more was 2.5 percentage points. In contrast to other studies, the absolute change in mortality was nearly the same compared to the qSOFA and SIRS criteria, and the qSOFA score had the greatest percentage increase of 104%, compared to 71% for the SOFA score and 50% for the SIRS criteria. Besides, from the perspective of discriminatory capacities, an increase in SOFA scores of 2 or more did not demonstrate significantly greater prognostic accuracy for in-hospital mortality than equivalent increases in qSOFA scores or SIRS criteria. These findings suggest distinctive characteristics of the study population in the CTICU that are different from the general population.

To extubate or not to extubate: Risk factors for extubation failure and deterioration with further mechanical ventilation.

BACKGROUND: Extubation is a critical step in the intensive care unit (ICU). In this study, we aim to investigate the risk factors for both extubation failure and deterioration with further mechanical ventilation (MV). METHODS: Data were collected from a cardiothoracic ICU in a tertiary hospital. The risk factors for extubation failure and deterioration with further MV were investigated by multivariate logistic regression. RESULTS: A total of 676 patients were enrolled in the study. Patients with extubation failure had a longer ICU length of stay and a higher mortality rate than patients without extubation failure. An age greater than 65 years, abnormal heart rate, respiratory rate exceeding 20 times/min, arterial pH lower than 7.35, pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FiO2) ratio lower than 300 mmHg, mean arterial pressure lower than 70 mmHg, duration of MV longer than 12 hours, and high quick Sequential Organ Failure Assessment (qSOFA) score were independent risk factors for extubation failure. Furthermore, we found that a respiratory rate greater than 20 times/min and a PaO2/fraction of Inspired Oxygen FiO2 ratio less than 300 mmHg were protective factors, while a mean arterial pressure lower than 70 mmHg, arterial pH lower than 7.35, and high qSOFA score were risk factors for deterioration on continued MV. CONCLUSIONS: Since the duration of MV increases the risk of extubation failure, physicians should consider not only the risk of extubation failure but also the risk of deterioration with further MV.

Bedside pleural procedures by pulmonologists and non-pulmonologists: a 3-year safety audit.

BACKGROUND AND OBJECTIVE: Pleural procedures such as tube thoracostomy and chest aspirations are commonly performed and carry potential risks of visceral organ injury, pneumothorax and bleeding. In this context limited information exists on the complication rates when non-pulmonologists perform ultrasound-guided bedside pleural procedures. Bedside pleural procedures in our university hospital were audited to compare complication rates between pulmonologists and non-pulmonologists. METHODS: A combined safety approach using standardized training, pleural safety checklists and ultrasound-guidance was initially implemented in a ∼1000-bed academic medical centre. A prospective audit, over approximately 3.5 years, of all bedside pleural procedures excluding procedures done in operating theatres and radiological suites was then performed. RESULTS: Overall, 529 procedures (295 by pulmonologists; 234 by non-pulmonologists) for 443 patients were assessed. There were 16 (3.0%) procedure-related complications, all in separate patients. These included five iatrogenic pneumothoraces, four dry taps, four malpositioned chest tubes, two significant chest wall bleeds and one iatrogenic hemothorax. There were no differences in complication rates between pulmonologists and non-pulmonologists. Presence of chronic obstructive pulmonary disease (COPD) independently increased the risk of complications by nearly sevenfold. CONCLUSIONS: Results from this study support pleural procedural practice by both pulmonologists and non-pulmonologists in an academic medical centre setting. This is possible with a standard training program, pleural safety checklists and relatively high utilization rates of ultrasound guidance for pleural effusions. Nonetheless, additional vigilance is needed when patients with COPD undergo pleural procedures.

Stem cell transplantation: potential impact on heart failure.

Cell transplantation is a promising new modality in treating damaged myocardium after myocardial infarction and in preventing postmyocardial infarction LV remodelling. Two strategies are plausible: the first uses adult tissue stem cells to replace the scar tissues and amend the lost myocardium, whilst the second strategy uses embryonic stem cells in an attempt to regenerate myocardium and/or blood vessels.

Anastomosis of small arteries: implications for coronary artery grafts in Asians.

The internal mammary artery (IMA) in patients with small body surface area, frequently found in the Asian population, is often small and delicate and can be easily damaged during suturing, particularly at the "toe" of the anastomosis. This may lead to less frequent utilization of the IMA as a bypass conduit. We describe a technique for anastomosing a small-caliber IMA to a coronary artery, using the tip of the graft as an autologous buttress to reinforce the toe of the anastomosis.