Case Start Time Affects Intraoperative Transfusion Rates in Adult Cardiac Surgery: A Single-Center Retrospective Analysis.

OBJECTIVE: The goal of the study was to investigate the role time of day plays in perioperative outcomes. The authors examined intraoperative transfusion rates throughout the day in adult cardiac surgery patients. They hypothesized that the rate of transfusion changes with later case start times in scheduled cardiac surgery. DESIGN: Retrospective observational study. SETTING: Single academic medical center. PARTICIPANTS: Adults undergoing cardiac surgery involving cardiopulmonary bypass. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a composite variable of transfusion. The association between the time of day and the rate of transfusion was explored with a multivariate logistic regression to fit the effect of starting time as a cubic spline. There were 1,421 cases that met inclusion criteria. There were 1,220 cases that were matched for modeling. The estimated probability of a patient receiving a transfusion changed significantly with later case start times in the multivariable model after adjusting for initial hemoglobin, age, sex, height, ideal body weight, diabetes, peripheral vascular disease, stroke, chronic kidney disease, chronic obstructive pulmonary disease, duration of cardiopulmonary bypass, aortic cross clamp time, attending surgeon, and attending anesthesiologist (p = 0.032, C-statistic = 0.807, n = 1220). The estimated probability of receiving an intraoperative red blood cell transfusion increased with later case start times in the multivariable model (p = 0.027, C-statistic = 0.902, n = 1220). There was no difference in the probability of transfusion for plasma, cryoprecipitate, or platelets. CONCLUSIONS: The observed rate of intraoperative blood product transfusion changed with later case start times in a multivariable model of scheduled cardiac surgery.

A Prospective Comparison of Intraluminal and Extraluminal Placement of the 9-French Arndt Bronchial Blocker in Adult Thoracic Surgery Patients.

OBJECTIVE: To compare the standard intraluminal approach with the placement of the 9-French Arndt endobronchial blocker with an extraluminal approach by measuring the time to positioning and other relevant intraoperative and postoperative parameters. DESIGN: A prospective, randomized, controlled trial. SETTING: University hospital. PARTICIPANTS: The study comprised 41 patients (20 intraluminal, 21 extraluminal) undergoing thoracic surgery. INTERVENTION: Placement of a 9-French Arndt bronchial blocker either intraluminally or extraluminally. Comparisons between the 2 groups included the following: (1) time for initial placement, (2) quality of isolation at 1-hour intervals during one-lung ventilation, (3) number of repositionings during one-lung ventilation, and (4) presence or absence of a sore throat on postoperative days 1 and 2 and, if present, its severity. MEASUREMENTS AND MAIN RESULTS: Median time to placement (min:sec) in the extraluminal group was statistically faster at 2:42 compared with 6:24 in the intraluminal group (p < 0.05). Overall quality of isolation was similar between groups, even though a significant number of blockers in both groups required repositioning (extraluminal 47%, intraluminal 40%, p > 0.05), and 1 blocker ultimately had to be replaced intraoperatively. No differences in the incidence or severity of sore throat postoperatively were observed. CONCLUSIONS: A statistically significant reduction in time to placement using the extraluminal approach without any differences in the rate of postoperative sore throat was observed. Whether placed intraluminally or extraluminally, a significant percentage of Arndt endobronchial blockers required at least one intraoperative repositioning.

Ethical considerations in adherence research.

Poor adherence to treatment is a common cause of medical treatment failure. Studying adherence is complicated by the potential for the study environment to impact adherence behavior. Studies performed without informing patients about adherence monitoring must balance the risks of deception against the potential benefits of the knowledge to be gained. Ethically monitoring a patient's adherence to a treatment plan without full disclosure of the monitoring plan requires protecting the patient's rights and upholding the fiduciary obligations of the investigator. Adherence monitoring can utilize different levels of deception varying from stealth monitoring, debriefing after the study while informing the subject that some information had been withheld in regard to the use of adherence monitoring (withholding), informed consent that discloses some form of adherence monitoring is being used and will be disclosed at the end of the study (authorized deception), and full disclosure. Different approaches offer different benefits and potential pitfalls. The approach used must balance the risk of nondisclosure against the potential for confounding the adherence monitoring data and the potential benefits that adherence monitoring data will have for the research subjects and/or other populations. This commentary aims to define various methods of adherence monitoring and to provide a discussion of the ethical considerations that accompany the use of each method and adherence monitoring in general as it is used in clinical research.

Disseminated mucormycosis in an adolescent with newly diagnosed diabetes mellitus.

We report a 16-year-old, previously healthy female who presented with disseminated mucormycosis leading to multiorgan failure and death with newly diagnosed type 1 diabetes mellitus and ketoacidosis. We review previous reported cases of mucormycosis in children with diabetes to demonstrate that this uncommon invasive infection may cause significant morbidity and mortality in this population.