The British Transplantation Society guidelines on cardiothoracic organ transplantation from deceased donors after circulatory death.

Maximising organ utilisation from donation after circulatory death (DCD) donors could help meet some of the shortfall in organ supply, but it represents a major challenge, particularly as organ donors and transplant recipients become older and more medically complex over time. Success is dependent upon establishing common practices and accepted protocols that allow the safe sharing of DCD organs and maximise the use of the DCD donor pool. The British Transplantation Society 'Guideline on transplantation from deceased donors after circulatory death' has recently been updated. This manuscript summarises the relevant recommendations from chapters specifically related to transplantation of cardiothoracic organs.

Pharmacovigilance in Herbal Drugs: A Challenge.

There is a growing awareness of a disease at many levels, its treatment, and treatment outcomes including side effects. Alternative therapy techniques, herbal medicines and formulations are extensively acknowledged and practiced in India and around the world. Herbal medicine is usually considered being safe regardless of the absence of scientific evidence to support its claims. Several issues concerning the methods in which herbal medications are labelled, evaluated, sourced, and used are connected to herbal medicine. Herbal therapeutics in the management and treatment of diabetes, rheumatism, hepatic disorders and other mild to chronic diseases and disorders are widely accepted. However, the adversities are difficult to recognize. The idea that the nature is safe and may be taken without the prescription of a physician has resulted in widespread self-medication across the world, sometimes with disappointing results, side effects, or unpleasant after-effects. The existing pharmacovigilance paradigm and its accompanying tools were created in connection with synthetic medicines. Nevertheless, adopting these approaches to keep records of herbal medications' safety poses a distinct challenge. This might be due to the variations in the usage of non-traditional medicines, which can offer unique toxicological issues whether taken alone or in conjunction with other medications. The goal of pharmacovigilance is to identify, analyse, explain, and minimize the adverse reactions and other drug-related complications associated with herbal, traditional, and complementary medications. Systematic pharmacovigilance is required to collect accurate data on the safety of herbal medications to create adequate guidelines for effective and safe usage.

Novel hybrids of thiazolidinedione-1,3,4-oxadiazole derivatives: synthesis, molecular docking, MD simulations, ADMET study, in vitro, and in vivo anti-diabetic assessment.

As compared to standard medicinal compounds, hybrid molecules that contain multiple biologically active functional groups have greater affinity and efficiency. Hence based on this concept, we predicted that a combination of thiazolidinediones and 1,3,4-oxadiazoles may enhance α-amylase and α-glucosidase inhibition activity. A series of novel 3-((5-phenyl-1,3,4-oxadiazol-2-yl)methyl)thiazolidine-2,5-dione derivatives (5a-5j) were synthesized and characterized using different spectroscopic techniques i.e., FTIR, 1H-NMR, 13C-NMR and MS. To evaluate in silico, molecular docking, MMGBSA, and MD simulations were carried out which were further evaluated via in vitro inhibition of α-amylase and α-glycosidase enzyme inhibition assays. In addition, the in vivo study was performed on a genetic model of Drosophila melanogaster to assess the antihyperglycemic effects. The compounds (5a-5j) demonstrated α-amylase and α-glucosidase inhibitory activity in the range of IC50 values 18.42 ± 0.21-55.43 ± 0.66 µM and 17.21 ± 0.22-51.28 ± 0.88 µM respectively when compared to standard acarbose. Based on the in vitro studies, compounds 5a, 5b, and 5j were found to be potent against both enzymes. In vivo studies have shown that compounds 5a, 5b, and 5j lower glucose levels in Drosophila. These compounds could be further developed in the future to produce a new class of antidiabetic agents.

Current Drug Targets in Alzheimer's Associated Memory Impairment: A Comprehensive Review.

Alzheimer's disease (AD) is the most prevalent form of dementia among geriatrics. It is a progressive, degenerative neurologic disorder that causes memory and cognition loss. The accumulation of amyloid fibrils and neurofibrillary tangles in the brain of AD patients is a distinguishing feature of the disease. Therefore, most of the current therapeutic goals are targeting inhibition of beta-amyloid synthesis and aggregation as well as tau phosphorylation and aggregation. There is also a loss of the cholinergic neurons in the basal forebrain, and first-generation therapeutic agents were primarily focused on compensating for this loss of neurons. However, cholinesterase inhibitors can only alleviate cognitive symptoms of AD and cannot reduce the progression of the disease. Understanding the molecular and cellular changes associated with AD pathology has advanced significantly in recent decades. The etiology of AD is complex, with a substantial portion of sporadic AD emerging from unknown reasons and a lesser proportion of early-onset familial AD (FAD) caused by a mutation in several genes, such as the amyloid precursor protein (APP), presenilin 1 (PS1), and presenilin 2 (PS2) genes. Hence, efforts are being made to discover novel strategies for these targets for AD therapy. A new generation of AChE and BChE inhibitors is currently being explored and evaluated in human clinical trials for AD symptomatic treatment. Other approaches for slowing the progression of AD include serotonergic modulation, H3 receptor antagonism, phosphodiesterase, COX-2, and MAO-B inhibition. The present review provides an insight into the possible therapeutic strategies and their molecular mechanisms, enlightening the perception of classical and future treatment approaches.

Transfusion requirement prediction score for patients undergoing cardiac surgery: An experience from a tertiary care set-up from South India.

BACKGROUND: Prediction of transfusion requirement is part of preoperative management in a surgical case. We aimed to develop one such tool for patients undergoing cardiac surgery. METHODS: A retrospective study for a period of 3 years was done to develop the scoring tool, Transfusion Requirement Prediction Score for Cardiac Surgery (TRPS), and internal validation was done prospectively. The primary outcome was administration of allogenic red cell units to the patients during perioperative period. The outcome is dichotomized as controls and cases based on the number of Red Blood Cell units received. Independent variables were chosen based on statistical significance and clinical judgement. Receiver operating characteristic curve was used to obtain the cut-off for each independent variable, odds ratio, and regression coefficients were used to assign the score. All patients with a cumulative score below the cut-off value were categorised as 'low risk' and above the cut off as 'high risk' group. RESULTS: During the study period, out of 602 patients, 345 met the inclusion criteria (controls: 175; cases: 170). Six variables such as age (more than 58 years), gender (female), bypass time (more than 148 min), haemoglobin (less than 12.5 g/dL), ejection fraction (less than 57%), and history of warfarin prophylaxis were chosen to develop the score. The total score value of 5 was chosen as the cut-off for the two risk groups. It predicted blood utilisation with a strength of 68% sensitivity and 79% specificity. On internal validation, the score was observed to have an accuracy of 70%. CONCLUSION: The TRPS is a simple reliable and handy tool with high accuracy.

ABO phenotype and SARS-CoV-2 infection: Is there any correlation?

COVID-19 is the currently evolving viral disease worldwide. It mainly targets the respiratory organs, tissues and causes illness. A plethora of studies has been performing to bring proper treatment and prevent people from the infection. Likewise, susceptibility to some infectious diseases has been associated with blood group phenotypes. The co-relationship of blood group with the occurrence of SARS-CoV-2 infection and death has been examined in numerous studies. This review explained the described studies regarding the correlation of blood group and the other essential factors with COVID-19.

Effects of foot massage and patient education in patients undergoing coronary artery bypass graft surgery: A randomized controlled trial.

BACKGROUND: Anxiety, pain, and fatigue are common postoperative problems that disturb the recovery and quality of life in patients undergoing coronary artery bypass graft (CABG) surgery. These postoperative problems are associated with prolonged recovery and decreased quality of life. This study was aimed at evaluating the combined effects of foot massage and patient education on anxiety, fatigue, pain, self-efficacy, and quality of life in patients undergoing CABG surgery. MATERIAL AND METHODS: In this randomized controlled trial (RCT), 130 participants were randomly allocated to experimental (n = 65) and control (n = 65) groups. The experimental group received a combination of foot massage and patient education as interventions and the control group received usual care of the hospital. RESULTS: The experimental group had a significant decrease in anxiety (p = 0.001), fatigue (p = 0.001), pain (p = 0.001), and increased self-efficacy (p = 0.001) and quality of life (p = 0.001). CONCLUSION: The combined form of foot massage and patient education is effective in decreasing anxiety, fatigue, pain, and increasing self-efficacy and the quality of life. These interventions will support the recovery of patients and reduce their suffering.

Application of two-dimensional binary fingerprinting methods for the design of selective Tankyrase I inhibitors.

In the present study, five important binary fingerprinting techniques were used to model novel flavones for the selective inhibition of Tankyrase I. From the fingerprints used: the fingerprint atom pairs resulted in a statistically significant 2D QSAR model using a kernel-based partial least square regression method. This model indicates that the presence of electron-donating groups positively contributes to activity, whereas the presence of electron withdrawing groups negatively contributes to activity. This model could be used to develop more potent as well as selective analogues for the inhibition of Tankyrase I. Schematic representation of 2D QSAR work flow.

Effect of Preoperative Education on Postoperative Outcomes Among Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis.

PURPOSE: The objective of this review was to assess the effect of preoperative education on postoperative outcomes among patients undergoing cardiac surgery. DESIGN: Systematic review and meta-analysis. METHODS: A comprehensive literature search was made on PubMed, CINAHL, Ovid, ProQuest, ScienceDirect, Scopus, Web of Science, and the Cochrane database between 1995 and 2015. Fourteen randomized controlled trials were included. Data analysis was performed with RevMan software and created the Supplementary Appendix using the GRADE approach. FINDINGS: Meta-analysis showed that preoperative education reduced anxiety scores (standardized mean difference = -0.96, 95% confidence interval: -1.37, -0.54; P < .0001). However, there was no significant effect of preoperative education on pain, depression, and length of hospital stay. There is low-quality evidence, and reasons for downgrading are due to study design limitations, inconsistency, and imprecision of effect estimates. CONCLUSIONS: The results show that preoperative education can effectively decrease anxiety in patients undergoing cardiac surgery.

Effect of Complementary Therapies in Patients Following Cardiac Surgery: A Narrative Review.

Cardiovascular diseases are increasing rapidly and have become a major health problem worldwide. The incidence and prevalence of cardiovascular disease are increasing rapidly, predominantly in the developing countries. Patients with cardiovascular disease who do not respond to routine medical treatment will have to follow cardiac surgical procedures. The objective of this study was to apprise the evidence of the effect of various complementary therapies on postoperative outcomes among patients undergoing cardiac surgery. A comprehensive literature search was made on PubMed-Medline, CINAHL, Science Direct, Scopus, Web of Science, and the Cochrane Library databases for original research studies published between 2000 and 2015. Original articles that reported the effect of complementary therapies in patients undergoing cardiac surgery were included. Twenty-eight studies were analyzed, and they have produced conflicting results. Most of the studies (n = 25) have documented the effects of complementary therapies on improving postoperative outcomes of patients, whereas other studies (n = 3) found no evidence of improvement. Although methods varied considerably, most of the studies included in this review reported positive results. Therefore, there is some evidence that complementary therapies can lead to positive postoperative outcomes. Evidence of the efficacy of complementary therapies in cardiac surgical patients remains inconclusive. Additional research is needed to provide a strong evidence base for the use of complementary therapies to improve postoperative outcomes and recovery in patients undergoing cardiac surgery.

Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery: a systematic review and meta-analysis.

BACKGROUND: Postcardiotomy cardiogenic shock (PCCS) refractory to inotropic support and intra-aortic balloon pump (IABP) occurs rarely but is almost universally fatal without mechanical circulatory support. In this systematic review and meta-analysis we looked at the evidence behind the use of veno-arterial extra-corporeal membrane oxygenation (VA ECMO) in refractory PCCS from a patient survival rate and determinants of outcome viewpoint. METHODS: A systematic review was performed in January 2017 using PubMed (with no defined time period) using the keywords "postcardiotomy", "cardiogenic shock", "extracorporeal membrane oxygenation" and "cardiac surgery". We excluded papers pertaining to ECMO following paediatric cardiac surgery, medical causes of cardiogenic shock, as well as case reports, review articles, expert opinions, and letters to the editor. Once the studies were collated, a meta-analysis was performed on the proportion of survivors in those papers that met the inclusion criteria. Meta-regression was performed for the most commonly reported adverse prognostic indicators (API). RESULTS: We identified 24 studies and a cumulative pool of 1926 patients from 1992 to 2016. We tabulated the demographic data, including the strengths and weaknesses for each of the studies, outcomes of VA ECMO for refractory PCCS, complications, and APIs. All the studies were retrospective cohort studies. Meta-analysis of the moderately heterogeneous data (95% CI 0.29 to 0.34, p < 0.01, I 2  = 60%) revealed overall survival rate to hospital discharge of 30.8%. Some of the commonly reported APIs were advanced age (>70 years, 95% CI -0.057 to 0.001, P = 0.058), and long ECMO support (95% CI -0.068 to 0.166, P = 0.412). Postoperative renal failure, high EuroSCORE (>20%), diabetes mellitus, obesity, rising lactate whilst on ECMO, gastrointestinal complications had also been reported. CONCLUSION: Haemodynamic support with VA ECMO provides a survival benefit with reasonable intermediate and long-term outcomes. Many studies had reported advanced age, renal failure and prolonged VA ECMO support as the most likely APIs for VA ECMO in PCCS. EuroSCORE can be utilized to anticipate the need for prophylactic perioperative VA ECMO in the high-risk category. APIs can be used to aid decision-making regarding both the institution and weaning of ECMO for refractory PCCS.

Left maxillary artery pseudoaneurysm: a rare and late postoperative complication after head and neck cancer treatment.

We report a case of a 50-year-old man presented with pulsatile swelling in the left side of the face since 2 months and a continuous sinus discharge since 3 days. Three years earlier, he was operated for squamous cell carcinoma (SCC) of the left lower alveolus and underwent surgical excision with myocutaneous flap reconstruction, followed by chemoradiotherapy. CT angiogram of the expansile swelling revealed pseudoaneurysm of third part of the left maxillary artery and treated by surgical intervention.

Should we use mechanical valves in patients with end-stage renal disease?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether a mechanical or bioprosthetic valve is superior for immediate and long-term survival in patients with end-stage renal disease (ESRD) undergoing a valve replacement. Altogether more than 150 papers were found using the reported search; of which, eight represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There were no randomized controlled trials addressing the question. There was one systematic review and meta-analysis. All the other evidence was in the form of retrospective studies. The papers show that there is no significant difference in the results and survival between patients receiving a mechanical and those receiving a bioprosthetic valve. This was seen in the meta-analysis as well as the larger series of patients who underwent valve replacement. Bleeding complications were more common with mechanical valves. We conclude that the choice of valve for patients with ESRD should be determined by age, level of activity and patient choice. Due to the limited life expectancy of these patients, bioprosthetic valves should be considered, especially since there is no evidence of early degeneration of tissue valves in this subgroup of patients.

Surgery and tuberculosis.

PURPOSE OF REVIEW: Tuberculosis (TB) remains a global emergency and continues to kill 1.7 million people globally each year. In the UK, figures for TB are increasing especially in urban areas. There have been advances in imaging techniques as well as increasingly invasive medical interventions in both the diagnosis and treatment of this complex disease. Surgery continues to play an evolving and more challenging role in TB management as minimally invasive procedures can be increasingly used in diagnosis and treatment. Open surgical procedures continue to prove an important adjunct in the management of multidrug-resistant TB (MDR-TB) and the complications of TB. RECENT FINDINGS: Since the peak of surgical treatment for TB in the 1950s, surgery is currently mainly reserved for 'difficult-to-diagnose' or indeed 'difficult-to-treat' cases of TB. Improved diagnostics, medical imaging and invasive medical interventions have all enabled alternatives to early surgical intervention. As improving minimally invasive surgical techniques provide diagnostic and treatment options, older methods of surgically managing complex TB have been revisited. To date most of the studies are retrospective and observatory but large studies and meta-analyses are showing the continued role surgery has to play in the treatment of TB. SUMMARY: This review will focus on new diagnostic imaging techniques and medical interventions which may become increasingly available in both developing countries and in the Western world. It will also highlight the continued role of minimally invasive video-assisted thoracoscopic surgery as well as open surgery in managing TB and MDR-TB.

Use of gentamicin-collagen sponges in closure of sternal wounds in cardiothoracic surgery to reduce wound infections.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Are antibiotic implants like gentamicin-collagen implants useful in preventing sternal wound infections (SWIs)? Altogether, more than 484 papers were found using the reported search; of these, 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that most randomized controlled trials (RCTs) have been performed with gentamicin-collagen sponges for sternal closure. Two out of four RCTs showed a significant benefit of the implant in a reduction in superficial and deep SWIs in routine and emergency cardiac surgery. One RCT showed a significant reduction in superficial infections in 2005, a follow-up trial by the same group in 2009 showed a reduction in deep infections as well. Another group has shown a reduction in deep and superficial SWI with gentamicin implant, in an RCT on 800 patients, however have not published details of the complete trial. The third trial on 542 patients showed no benefit of the implant, but was not adequately powered. However, the most recent multicentre RCT conducted on 1052 patients showed no benefit of gentamicin-collagen sponges in elective surgery (coronary artery bypass grafting and/or valve surgery) in high-risk patients with diabetes, obesity or both. Concerns were raised that gentamicin sponges dipped in saline 1-2 s prior to application may have lost the gentamicin into the saline, thereby reducing their efficacy and that some surgeons may have been unfamiliar with wound closure with sponges. However, these were robustly refuted by the authors. One RCT showed that gentamicin sponges may cause increased sternal rebleeding if used in double layers. Coagulase-negative staphylococci were predominantly isolated from infected wounds in all the trials except the one from USA, where infections were polymicrobial. Gentamicin resistance among common pathogens causing SWIs can vary from 15 to 80%. Gentamicin-collagen is unlikely to reduce SWIs in high-risk patients and polymicrobial infections.

Are there any good treatments for keloid scarring after sternotomy?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with hypertrophic and keloid scarring of the sternotomy wound, is surgical excision with or without adjuvant treatment of any benefit in reducing the size of the scar? Altogether, more than 15 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. One of the studies showed no difference between surgery and adjunctive triamcinolone or colchicine. One study showed that incomplete excision resulted in higher recurrence rates. Postoperative radiation was found to be useful in two of the studies, although one study showed that it was not useful. One randomized control trial showed improvement after laser compared to no treatment. Two other trials showed no difference between laser, silicone gel, intralesional steroid or 5-fluorouracil. One trial showed that perioperative systemic steroid application gave rise to no improvement but in fact worsened scar formation. We conclude that small keloids can be treated radically by surgery with adjuvant therapy (radiation or corticosteroid injections) or by non-surgical therapy (corticosteroid injections, laser and anti-tumour/immunosuppressive agents, such as 5-fluorouracil). Large and multiple keloids are difficult to treat radically and are currently only treatable by multimodal therapies that aim to relieve symptoms.

Efficacy of three different ablative procedures to treat atrial fibrillation in patients with valvular heart disease: a randomised trial.

OBJECTIVES: Various modifications have been proposed to the original Cox's Maze procedure due to concerns about the long bypass and cross clamp times. The efficacy of these procedures has been studied and reported. We conducted a randomised prospective study to compare three procedures, differing in extent, of ablation in patients in atrial fibrillation who were undergoing surgery for rheumatic valvular heart disease. These procedures utilised radiofrequency in the bipolar mode. The extent of ablation was (1) biatrial (replication of the Cox Maze) (2) left atrial portion of the Cox Maze and (3) pulmonary vein isolation along with a control group (the No Maze group). Conversion rate to sinus rhythm was studied over a mid-term follow-up period. METHODS: A total of 160 patients were studied with 40 patients in each group. Antiarrhythmic drugs were not used in the three months preceding surgery and for seven days postoperatively. The patients underwent surgery for their valve disease along with the ablative procedure as per randomisation using radiofrequency microbipolar coagulation and cryoablation. They were followed up and were evaluated for symptomatic improvement, rhythm with ECG documentation and 2D echocardiography. RESULTS: Follow-up was available for 133 patients. Mid-term results showed that sinus rhythm was restored in 62.5% patients of Biatrial Maze group and 57.5% in the Left Atrial Maze. In the Pulmonary Vein Isolation Maze group, 67.5% patients converted to NSR whereas in the No Maze group only 20% patients were in sinus rhythm (p value for all the groups was 0.001 when compared to the No Maze group). The incidence of other arrhythmias was not significant and there were no other major complications. All the patients in sinus rhythm at follow-up were in NYHA functional class I-II and showed good effort tolerance. CONCLUSIONS: Results achieved with the three ablative procedures are comparable. Therefore lesser procedures viz. Left Atrial Maze and the Pulmonary Vein Isolation Maze procedures must be studied further with the additional use of antiarrhythmic drugs.

How best to manage the space after pneumonectomy? Theory and experience but no evidence.

OBJECTIVE: We set out to find a policy for the management of the pneumonectomy space which would minimise risk and be acceptable to all the surgeons. We believe this will reduce opportunities for error, be welcomed by nursing staff, and improve adherence to protocols. METHODS: We sought evidence in the scientific and educational literature. Finding no sure guidance, we audited our own experience of two policies, with the emphasis on minimising risk. RESULTS: There was no evidence from randomised trials. There was no cohesive advice in the text books. Our data indicated that it was improbable that randomised controlled trial (RCT) would have the power to find the evidence. Unable to establish the best strategy, we chose what appeared to be the lowest risk management policy. CONCLUSIONS: It is instructive that such a fundamental question should be unanswered. We have adopted a low risk and well established strategy--an unclamped underwater seal drain--but have no evidence base other than clinical experience. This is illustrative of much of what we do in clinical surgical practice. Avoiding major risk is often more important than proving small differences in benefit.