Risk factors for post sternotomy wound complications across the patient journey: A systematised review of the literature.

BACKGROUND: Around 36,000 cardiac operations are undertaken in the United Kingdom annually, with most procedures undertaken via median sternotomy. Wound complications occur in up to 8% of operations, with an associated mortality rate of around 47% in late or undetected cases. OBJECTIVE: To undertake a systematised literature review to identify pre-operative, peri-operative and post-operative risk factors associated with sternal wound complications. METHODS: Healthcare databases were searched for articles written in the English language and published between 2013 and 2021. Inclusion criteria were quantitative studies involving patients undergoing median sternotomy for cardiac surgery; sternal complications and risk factors. RESULTS: 1360 papers were identified, with 25 included in this review. Patient-related factors included: high BMI; diabetes; comorbidities; gender; age; presenting for surgery in a critical state; predictive risk scores; vascular disease; severe anaemia; medication such as steroids or α-blockers; and previous sternotomy. Peri-operative risk increased with specific types and combinations of surgical procedures. Sternal reopening was also associated with increased risk of sternal wound infection. Post-operative risk factors included a complicated recovery; the need for blood transfusions; respiratory complications; renal failure; non-diabetic hyperglycaemia; sternal asymmetry and sepsis. CONCLUSION: Pre, peri and post-operative risk factors increase the risk of sternal wound complications in cardiac surgery. Generic risk assessment tools are primarily designed to provide mortality risk scores, with their ability to predict risk of wound infection questionable. Tools that incorporate factors throughout the operative journey are required to identify patients at risk of surgical wound infection.

Should I stay or should I go? An exploration of the decision-making behavior of acute cardiac patients during the COVID-19 pandemic.

BACKGROUND: During the SARS-COV-2 (COVID-19) pandemic efforts to reduce virus transmission resulted in non-emergency patients being deterred from seeking help. The number of patients presenting with acute cardiac conditions reduced, significantly OBJECTIVES: To explore the decision-making process, and influential factors in that process, of patients and their family during an acute cardiac event. METHODS: A qualitative research design was employed using purposive sampling of patients who experienced an acute cardiac event during the social containment mandates. Semi-structured interviews were conducted, with thematic analysis of interview transcripts. RESULTS: Twenty-five participants were recruited from three UK hospitals. Themes identified were reliance on informal support network, lack of awareness of cardiac symptoms leading to delayed help-seeking, and an indirect COVID-19 effect (e.g. avoiding treatment). CONCLUSIONS: These results highlight the need for informed public health messages, targeting patients and their support networks, that allow those in need of treatment to access care.

Computed tomographic findings in 12 cases of canine multi-centric lymphoma with splenic and hepatic involvement.

OBJECTIVES: To describe the CT findings in a population of dogs with multi-centric lymphoma that involved the spleen and liver. MATERIALS AND METHODS: Clinical records between January 2008 and June 2015 were reviewed. Thoracic and abdominal CT examinations of patients diagnosed with multi-centric lymphoma were evaluated by a board-certified radiologist. A diagnosis of multi-centric lymphoma with splenic and hepatic involvement was based upon cytological identification and immunophenotyping of neoplastic lymphocytes in cellular samples harvested from a peripheral lymph node, the spleen and the liver. RESULTS: Twelve dogs were included in this study, of which 11 had B-cell lymphoma; immunophenotyping was inconclusive in one dog. The spleen appeared normal in seven dogs and nodules were identified in five dogs. Splenic nodules were hypoattenuating in four of five dogs and isoattenuating in one of five. After contrast administration, three of five appeared hypoattenuating and two of five isoattenuating. The liver appeared normal in 10 dogs and hepatic nodules were identified in two dogs. All hepatic nodules were isoattenuating before contrast and hypoattenuating following contrast administration. CLINICAL SIGNIFICANCE: The CT appearance of the spleen and liver was normal in the majority of dogs with multi-centric lymphoma. Fine needle aspiration of the spleen and liver is recommended when using CT to stage dogs with multi-centric lymphoma.

Associations between respiratory signs and abnormalities reported in thoracic CT scans of cats.

OBJECTIVES: To estimate the prevalence of subclinical abnormalities reported in thoracic (CT) scans of cats and to investigate associations between respiratory signs and CT signs. METHODS: Retrospective review of signalment, indications, respiratory signs and reported CT findings in a series of cats. Associations between patient variables, respiratory signs and CT signs were analysed using multi-variable regression methods. RESULTS: Records of 352 consecutive cats were reviewed. Abnormalities affecting thoracic structures were reported in CT scans of 138/179 (77%) cats that did not have respiratory signs; the most prevalent CT findings were pulmonary collapse (41%), evidence of bronchial disease (24%) and space-occupying lesions (21%). Dyspnoea, cough and tachypnoea were associated with space-occupying lesions. Dyspnoea was also associated with pulmonary consolidation and atelectasis. Increasing body weight was associated with pulmonary atelectasis and increasing age was associated with evidence of bronchial disease. CLINICAL SIGNIFICANCE: Abnormalities were commonly detected in thoracic CT scans of cats that did not show respiratory signs. The most prevalent abnormality - pulmonary atelectasis - is probably a temporary effect of sedation or anaesthesia. A high prevalence of subclinical abnormalities and limited correlations between clinical signs and CT findings will complicate diagnosis.

Flow-mediated vasodilation measurements in Cavalier King Charles Spaniels with increasing severity of myxomatous mitral valve disease.

BACKGROUND: Cardiovascular disease is associated with endothelial dysfunction in humans and studies of plasma biomarkers suggest that dogs with myxomatous mitral valve disease (MMVD) might also have endothelial dysfunction. HYPOTHESIS: That progression of mitral regurgitation (MR) is associated with development of endothelial dysfunction. ANIMALS: Forty-three Cavalier King Charles Spaniels (CKCS) with MR of varying severity. METHODS: Privately owned CKCS were prospectively recruited and divided in 4 groups: (1) 12 CKCS with minimal MR; (2) 9 CKCS with mild MR; (3) 11 CKCS with moderate-severe MR; and (4) 11 CKCS with moderate-severe MR and clinical signs compatible with heart failure. Dogs underwent blood sampling, echocardiography, blood pressure (BP) recordings, and flow-mediated vasodilation (FMD) measurements. The effect of progressive MR on FMD was determined by multivariate analyses. RESULTS: Flow-mediated vasodilation decreased with progression of MR. Group 4 (4.79 ± 3.22%) had significantly lower FMD than groups 1 (10.40 ± 4.58%) and 2 (10.14 ± 3.67%) (P < .005) and group 3 (6.79 ± 3.98%) had a significantly lower FMD than group 1 (P = .03). Increasing left ventricular end-diastolic diameter (P = .0004, R(2) = 0.27) and the combination of age (P = .01) and body weight (P = .002) (R(2) = 0.31) were significantly associated with reduced FMD. FMD did not correlate with sex, BP, or plasma markers. CONCLUSIONS AND CLINICAL IMPORTANCE: Reduced FMD indicates that increased disease severity in CKCS with MMVD is associated with development of endothelial dysfunction which might be a future therapeutic and/or diagnostic target.

Factors contributing to the contamination of peripheral intravenous catheters in dogs and cats.

The aim of this study was to identify factors that contribute significantly to the bacterial contamination of peripheral intravenous catheters in dogs and cats. Between January and June 2005, intravenous catheters were removed from 84 dogs and 15 cats at the Queen Mother Hospital for Animals, Royal Veterinary College. None of the factors under consideration was significantly associated with bacterial contamination, but 42.9 per cent of the animals with clinical signs consistent with a peripheral catheter-related infection, 34.8 per cent of the animals in which blood had been collected from the catheter immediately after its insertion, and 21.1 per cent of the animals in which a T-connector rather than a Y-connector had been used had contaminated cannulae, compared with 19.0 per cent, 19.7 per cent and 8.3 per cent, respectively, of the animals that did not have signs of such an infection, from which blood was not taken immediately, and that had a Y-connector rather than a T-connector. Binary logistic regression showed that the animals with clinical signs of a catheter-related infection were 10 times more likely to have a contaminated catheter (odds ratio [OR] 10.9, 95 per cent confidence interval [CI] 0.89 to 134) and the animals fitted with Y-connectors rather than T-connectors were 10 times less likely to have a contaminated catheter (OR 0.10, 95 per cent CI 0.008 to 1.25).

Emergency department evaluation of the chest pain patient.

The emergency physician must have a high degree of suspicion for myocardial ischemia in patients presenting with no obvious for their chest pain. The role of the emergency physician is to determine a relative risk for each patient and to order the appropriate studies to minimize the risk of missed myocardial infarction as well as to recognize acute ischemia or infarction and manage it aggressively. It is not possible to rule out myocardial ischemia or infarction subjectively. It is the opinion of these authors that some form of further testing should be performed on patients in all categories, except those determined to be at very low risk.

Leukocytes in semen from men with spinal cord injuries.

OBJECTIVE: To assess the leukocyte populations in semen samples from men with spinal cord injuries (SCIs) and their relation to sperm motility. DESIGN: Cross-sectional study. SETTING: A joint spinal cord injury and fertility clinic at an academic tertiary referral center for fertility treatment and a university-based department of immunology. PATIENT(S): Nine men with chronic SCIs and seven healthy sperm donors as controls. INTERVENTION(S): Semen samples were obtained by electroejaculation from men with SCIs and by masturbation from donors. MAIN OUTCOME MEASURE(S): Leukocyte populations determined by immunohistochemical techniques, bacteriologic assessment of urine, and sperm density and motility. RESULT(S): The most cellular specimens were antegrade specimens obtained from men with SCIs and coexisting urinary tract infections. The highest proportion of leukocytes occurred in retrograde samples from men with SCIs and urinary tract infections. The most predominant leukocytes in all specimens were granulocytes. Infection increased the number of T cells and the degree of cell activation. There was no significant correlation between leukocyte populations and total motile sperm counts. CONCLUSION(S): Increased numbers of leukocytes in semen samples from men with SCIs are the result of urinary tract infections. The reduced sperm motility seen in men with SCIs does not correlate with the numbers of leukocytes; therefore, other factors also contribute to the semen abnormalities in these patients.

Biogenesis and regulation of the Vibrio cholerae toxin-coregulated pilus: analogies to other virulence factor secretory systems.

Biogenesis of the toxin-coregulated pilus (TCP) of Vibrio cholerae 01 is essential for successful bacterial colonization of the small intestine. Pilus assembly requires the products of at least seven genes located on the chromosome adjacent to the pilin-encoding gene, tcpA. Previously reported TnphoA insertions in the TCP-assembly-deficient V. cholerae strains, KP2.21 and KP4.2, were isolated from the chromosome for further analysis. Nucleotide sequencing of the tcpE::phoA and tcpF::phoA fusions and corresponding clones of the region containing the intact genes revealed the presence of two open reading frames (ORFs) of 340 and 338 amino acids, designated TcpE and TcpF, respectively. The partial sequence of an ORF downstream from the TcpF coding sequence was determined to correspond to the global virulence regulator, ToxT. Proteins corresponding to the observed ORFs were visualized with the T7 promoter/RNA polymerase expression system. Computer-generated alignment algorithms predict that a homology exists between TcpE and the Klebsiella pneumoniae pullulanase secretion proteins PulD and PulF, the Xanthomonas campestris extracellular enzyme secretion factor XpsF, the Bacillus subtilis DNA competence protein ComG-ORF2, and the Yersinia enterocolitica Yop secretion determinant YscC. These observations provide a model to investigate further the relationship between the secretion mechanisms utilized by these seemingly diverse virulence determinants. Additionally, an extreme C-terminal segment of TcpE shows striking homology to the transmembrane segment of the eukaryotic integrin beta-1 chain, which could imply a role for TcpE in not only TCP secretion, but also host cell interaction.