A multicentre cross-sectional descriptive study evaluating the cardiovascular risk profile of preoperatively identified patients with hypertension.

BACKGROUND: The prevalence of hypertension in adults in South Africa (SA) is 35%. Hypertension is the most important modifiable risk factor for cardiovascular (CV) and chronic kidney disease (CKD) in sub-Saharan Africa. However, 49% of people are unaware of their blood pressure status. Screening for hypertension prior to surgery provides a unique opportunity to diagnose and treat affected individuals. Furthermore, assessing overall CV risk identifies patients at highest risk for complications, and improves the utilisation of scarce resources. OBJECTIVES: To evaluate the CV risk profile of hypertensive patients in the adult population of the Western Cape Province presenting for elective non-cardiac, non-obstetric surgery. METHODS: This report documents the CV risk profile of patients recruited to the HASS-2 study (Hypertension and Surgery Study 2), which was undertaken in seven Western Cape hospitals. Patients were screened for hypertension and pharmacological treatment was initiated or adjusted in patients with stages 1 and 2 disease. Stage 3 patients were referred to a physician. In the present substudy, patients with stages 1 and 2 hypertension were assessed for associated CV risk factors, the presence of target organ damage, and documented CV or kidney disease; they received an overall risk stratification according to the 2018 European Society of Cardiology and the European Society of Hypertension Guidelines. RESULTS: Sixty-one patients with stage 1 and 12 with stage 2 hypertension were analysed. Established CV disease was present in 13.7% of the study population, and CKD (eGFR <60 mL/min) in 10.8%. Seventy-one percent of the study group had a raised body mass index, and 55.9% underlying metabolic syndrome. Prediabetes and diabetes were present in 16.1% and 14.5%, respectively. According to the 2018 European guidelines, 34.7% were at moderate, 33.3% at high and 16.7% at very high risk for a CV event in the following 10 years. CONCLUSIONS: The perioperative period is a critical time during which surgeons, nurses and anaesthetists can influence patients' CV risk of adverse events. This involves appropriate screening, education and treatment. In this study population, nearly 9 out of 10 elective surgical patients with stage 1 or 2 hypertension had CV risk factors placing them at moderate to very high risk. The simultaneous assessment of these additional CV risk parameters, in addition to diagnosis and management of hypertension, may further decrease the health and financial burden in resource-limited facilities in SA, and improve CV outcomes.

Risk factors and interventions associated with mortality or survival in adult COVID-19 patients admitted to critical care: a systematic review and meta-analysis

Patients with confirmed COVID-19 admitted to intensive care units have a high mortality rate, which appears to be associated with increasing age, male sex, smoking history, hypertension and diabetes mellitus. Methods: A systematic review to determine risk factors and interventions associated with mortality/survival in adult patients admitted to an intensive care unit (ICU) with confirmed COVID-19/SARS-CoV-2 infection. The protocol was registered with PROSPERO (CRD42020181185).Results: The search identified 483 abstracts between 1 January and 7 April 2020, of which nine studies were included in the final review. Only one study was of low bias. Advanced age (odds ratio [OR] 11.99, 95% confidence interval [CI] 5.35­18.62) and a history of hypertension were associated with mortality (OR 4.17, 95% CI 2.90­5.99). Sex was not associated with mortality. There was insufficient data to assess the association between other comorbidities, laboratory results or critical care risk indices and mortality.The critical care interventions of mechanical ventilation (OR 6.25, 95% CI 0.75­51.93), prone positioning during ventilation (OR 2.06, 95% CI 0.20­21.72), and extracorporeal membrane oxygenation (ECMO) (OR 8.00, 95% CI 0.69, 92.33) were not associated with mortality. The sample size was insufficient to conclusively determine the association between these interventions and ICUmortality. The need for inotropes or vasopressors was associated with mortality (OR 6.36, 95% CI 1.89­21.36). Conclusion: The studies provided little granular data to inform risk stratification or prognostication of patients requiring intensive

A multicentre prospective observational study of the prevalence of preoperative anaemia and iron deficiency in adult elective surgical patients in hospitals in Western Cape Province, South Africa.

BACKGROUND: Preoperative anaemia has been shown to be an independent risk factor for postoperative morbidity and mortality. Iron deficiency is the leading cause of anaemia globally. There are limited data describing the burden of perioperative anaemia and the relative contribution of iron deficiency in South Africa (SA). OBJECTIVES: To determine the prevalence and severity of preoperative anaemia in adults presenting for elective surgery in Western Cape Province, SA, and to investigate the contribution of iron deficiency as a cause of the anaemia. For this purpose, an investigative protocol from a recent consensus statement on the management of perioperative anaemia was applied. METHODS: We performed a prospective, observational study in adult patients presenting for elective non-cardiac, non-obstetric surgery over a 5-day period at six Western Cape government-funded hospitals. The World Health Organization patient classification was applied, and patients with anaemia were investigated for iron deficiency. RESULTS: The prevalence of preoperative anaemia was 28% (105/375; 95% confidence interval (CI) 23.5 - 32.5); 55/105 patients (52%) had moderate and 11/105 (11%) severe anaemia. Iron deficiency was the cause of anaemia in 37% (32/87; 95% CI 26.6 - 46.9), but only 9% of iron-deficient patients received iron supplementation prior to surgery. CONCLUSIONS: Preoperative anaemia was common in this study, and more than half of the affected patients had moderate to severe anaemia. Iron deficiency was responsible for almost 40% of cases. Iron supplementation was under-utilised in the preoperative period as a means of increasing haemoglobin. The introduction of system-wide policies would empower perioperative physicians to mitigate the risk associated with preoperative anaemia in the Western Cape.

A multicentre prospective observational study of the prevalence and glycaemic control of diabetes mellitus in adult non-cardiac elective surgical patients in hospitals in Western Cape Province, South Africa.

BACKGROUND: Diabetes mellitus (DM) is a common condition. The high burden of undiagnosed DM and a lack of large population studies make accurate prevalence estimations difficult, especially in the surgical environment. Furthermore, poorly controlled DM is associated with an increased risk of perioperative complications and mortality. OBJECTIVES: The primary objective was to establish the prevalence of DM in elective adult non-cardiac, non-obstetric surgical patients in hospitals in Western Cape Province, South Africa. The secondary objectives were to assess the glycaemic control and compliance with treatment of known diabetics. METHODS: A 5-day multicentre, prospective observational study was performed at six government-funded hospitals in the Western Cape. Screening for DM was done using finger-prick capillary blood glucose (CBG) testing. Patients found to have a CBG ≥6.5 mmol/L had their glycated haemoglobin (HbA1c) level measured. DM was diagnosed based on the Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) diagnostic criteria. Patients known to have DM had their HbA1cmeasured and completed a Morisky Medication Adherence Scale (MMAS-4) questionnaire to assess glycaemic control and compliance with treatment. RESULTS: Of the 379 participants, 61 were known diabetics (16.2%; 95% confidence interval (CI) 12.4 - 19.8). After exclusion of 8 patients with incomplete results, a new diagnosis of DM was made in 5/310 patients (1.6%; 95% CI 0.2 - 3.0). The overall prevalence of DM was 17.8% (66/371; 95% CI 13.9 - 21.7). HbA1c results were available for 57 (93.4%) of the 61 known diabetics. Of these, 27 (47.4%; 95% CI 34.4 - 60.3) had an HbA1c level ≥8.5% and 14 (24.6%; 95% CI 13.4 - 35.8) had a level ≤7%. Based on positive responses to two or more questions on the MMAS-4 questionnaire, 12/60 participants (20.0%) were deemed non-compliant. CONCLUSIONS: There is a low rate of undiagnosed DM in our elective surgical population, but in a high proportion of patients with DM the condition is poorly controlled. Poorly controlled DM is known to increase postoperative complications and is likely to increase the burden of perioperative care. Resources should be focused on improvement of long-term glycaemic control in patients presenting for elective surgery.

A multicentre, cross-sectional study investigating the prevalence of hypertensive disease in patients presenting for elective surgery in the Western Cape Province, South Africa.

BACKGROUND: Hypertension is common, affecting over one billion people worldwide. In sub-Saharan Africa, hypertensive disease not only affects the older population but is becoming increasingly prevalent in younger individuals. In South Africa (SA), >30% of the adult population has hypertension, making it the single most common cardiovascular risk factor and the predominant contributor to cardiovascular disease and mortality. Elevated blood pressure is the most common perioperative comorbidity encountered in non-cardiac surgical patients, with an overall prevalence of 20 - 25%, and it remains poorly controlled in low- and middle-income countries. Hypertension in the perioperative setting may adversely affect patient outcome. It therefore not only flags possible perioperative challenges to anaesthesiologists, but also identifies patients at risk of long-term morbidity and mortality. OBJECTIVES: To determine the prevalence and severity of hypertension in elective adult surgical patients in the Western Cape Province, SA. RESULTS: The study population included all elective surgical patients from seven hospitals in the Western Cape during a 1-week period. Hypertension, defined as having had a previous diagnosis of hypertension or meeting the blood pressure criteria of >140/90 mmHg, was identified in 51.8% of patients during preoperative assessment. Significantly, newly diagnosed hypertension was present in 9.9% of all patients presenting for elective surgery. Although 98.1% of the known hypertensive patients were on antihypertensive therapy, 36.9% were inadequately controlled. There are numerous reasons for this, but notably 32.1% of patients admitted to forgetting to take their medication, making patient factors the most common reason for treatment non-compliance. CONCLUSIONS: The perioperative period may be an important opportunity to identify undiagnosed hypertensive patients. The perioperative encounter may have a significant public health implication in facilitating appropriate referral and treatment of patients with hypertension to decrease long-term cardiovascular complications in SA.

The relationship between pre-operative hypertension and intra-operative haemodynamic changes known to be associated with postoperative morbidity.

Hypertension is not consistently associated with postoperative cardiovascular morbidity and is therefore not considered a major peri-operative risk factor. However, hypertension may predispose to peri-operative haemodynamic changes known to be associated with peri-operative morbidity and mortality, such as intra-operative hypotension and tachycardia. The objective of this study was to determine whether pre-operative hypertension was independently associated with haemodynamic changes known to be associated with adverse peri-operative outcomes. We performed a five-day multicentre, prospective, observational cohort study which included all adult inpatients undergoing elective, non-cardiac, non-obstetric surgery. We recruited 343 patients of whom 164 (47.8%) were hypertensive. An intra-operative mean arterial pressure of < 55 mmHg occurred in 59 (18.2%) patients, of which 25 (42.4%) were hypertensive. Intra-operative tachycardia (heart rate> 100 beats.min-1 ) occurred in 126 (38.9%) patients, of whom 61 (48.4%) were hypertensive. Multivariable logistic regression did not show an independent association between the stage of hypertension and either clinically significant hypotension or tachycardia, when controlled for ASA physical status, functional status, major surgery, duration of surgery or blood transfusion. There was no association between pre-operative hypertension and peri-operative haemodynamic changes known to be associated with major morbidity and mortality. These data, therefore, support the recommendation of the Joint Guidelines of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the British Hypertension Society to proceed with elective surgery if a patient's blood pressure is < 180/110 mmHg.

A meta-analysis of the efficacy of preoperative surgical safety checklists to improve perioperative outcomes

BACKGROUND:Meta-analyses of the implementation of a surgical safety checklist (SSC) in observational studies have shown a significant decrease in mortality and surgical complications.OBJECTIVE:To determine the efficacy of the SSC using data from randomised controlled trials (RCTs). METHODS:This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with PROSPERO (CRD42015017546). A comprehensive search of six databases was conducted using the OvidSP search engine.RESULTS:Four hundred and sixty-four citations revealed three eligible trials conducted in tertiary hospitals and a community hospital; with a total of 6 060 patients. All trials had allocation concealment bias and a lack of blinding of participants and personnel. A single trial that contributed 5 295 of the 6 060 patients to the meta-analysis had no detection; attrition or reporting biases. The SSC was associated with significantly decreased mortality (risk ratio (RR) 0.59; 95% confidence interval (CI) 0.42 - 0.85; p=0.0004; I2=0%) and surgical complications (RR 0.64; 95% CI 0.57 - 0.71; petlt;0.00001; I2=0%). The efficacy of the SSC on specific surgical complications was as follows: respiratory complications RR 0.59; 95% CI 0.21 - 1.70; p=0.33; cardiac complications RR 0.74; 95% CI 0.28 - 1.95; p=0.54; infectious complications RR 0.61; 95% CI 0.29 - 1.27; p=0.18; and perioperative bleeding RR 0.36; 95% CI 0.23 - 0.56; petlt;0.00001.CONCLUSIONS:There is sufficient RCT evidence to suggest that SSCs decrease hospital mortality and surgical outcomes in tertiary and community hospitals. However; randomised evidence of the efficacy of the SSC at rural hospital level is absent

Transthoracic echocardiographic assessment of haemodynamics in severe pre-eclampsia and HIV in South Africa.

Haemodynamic and cardiac structural changes in severe pre-eclampsia and in pregnant women with human immunodeficiency virus (HIV) infection have not been clearly established. We performed transthoracic echocardiography on 105 women. Women with pre-eclampsia demonstrated (mean (SD), untreated vs treated) preserved fractional shortening (40 (7.1)% vs. 41 (8.6)%), a non-dilated left ventricle (4.5 (0.49) cm vs. 4.4 (0.44) cm), increased mitral valve E/septal e' (10.5 (3.3) vs. 10.6 (2.8)), and preserved tricuspid annular plane systolic exertion (2.6 (0.36) cm vs. 2.4 (0.51) cm). Women with HIV infection demonstrated (mean (SD), HIV-positive vs healthy) a reduced cardiac index (2.8 (0.64) ml.min(-1) .m(-2) vs. 3.1 (0.7) ml.min(-1) .m(-2) , p = 0.029), reduced septal s' tissue Doppler velocity (8.5 (1.5) cm.s(-1) vs. 9.3 (1.7) cm.s(-1) , p = 0.042), increased left ventricular end-diastolic area (7.6 (2.1) cm2 vs. 6.3 (1.7) cm2 , p = 0.004), and reduced right ventricular s' and e' velocity (s' velocity 14.7 (3.1) cm.s(-1) vs. 7.0 (2.9) cm.s(-1) p = 0.001, e' velocity 16.3 (4.1) cm.s(-1) vs. 18.7 (3.4) cm.s(-1) , p = 0.013). The mitral value E/septal e' was > 8 in 39% of patients with HIV. Fractional shortening (< 28%) was reduced in 10% of healthy women, and mitral valve E/septal e' ratios were > 8 in 38% of that group. Women with pre-eclampsia demonstrated preserved systolic function, with diastolic dysfunction. Women with HIV demonstrated reduced left and right ventricular systolic function, with increased ventricular dilatation.

Point-of-Care Clinical Ultrasound for Medical Students.

PURPOSE: Our institution has recently implemented a point-of-care (POC) ultrasound training program, consisting of an e-learning course and systematic practical hands-on training. The aim of this prospective study was to evaluate the learning outcome of this curriculum. MATERIALS AND METHODS: 16 medical students with no previous ultrasound experience comprised the study group. The program covered a combination of 4 well-described point-of-care (POC) ultrasound protocols (focus assessed transthoracic echocardiography, focused assessment with sonography in trauma, lung ultrasound, and dynamic needle tip positioning for ultrasound-guided vascular access) and it consisted of an e-learning course followed by 4 h of practical hands-on training. Practical skills and image quality were tested 3 times during the study: at baseline, after e-learning, and after hands-on training. RESULTS: Practical skills improved for all 4 protocols; after e-learning as well as after hands-on training. The number of students who were able to perform at least one interpretable image of the heart increased from 7 at baseline to 12 after e-learning, p<0.01, and to all 16 students after hands-on-training, p<0.01. The number of students able to cannulate an artificial vessel increased from 3 to 8 after e-learning and to 15 after hands-on training. CONCLUSION: Medical students with no previous ultrasound experience demonstrated a considerable improvement in practical skill after interactive e-learning and 4 h of hands-on training.

Assessment of nociceptin/orphanin FQ and micro-opioid receptor mRNA in the human right atrium.

BACKGROUND: The expression of micro (mu: MOP) and nociceptin/orphanin FQ (NOP) receptors in the human myocardium is controversial. In this polymerase chain reaction (PCR)-based study using human right atrial biopsies, we have (i) probed for mRNA encoding NOP receptor and its endogenous peptide precursor, ppN/OFQ, and mRNA encoding MOP and (ii) attempted to correlate expression with cardiac function. METHODS: mRNA encoding MOP, NOP, and the precursor for NOP (ppN/OFQ) was assessed by quantitative real-time PCR (Q-PCR) using validated TaqMan primers and compared with a housekeeper (glyceraldehyde-3-phosphate dehydrogenase, GAPDH). Q-PCR data are expressed as the difference in cycle threshold (DeltaC(t)=C(tGene of interest)-C(tGAPDH): high value, low expression) and patients were grouped according to left ventricular ejection fraction (LVEF). RESULTS: Forty patients were recruited; NOP, MOP, and ppN/OFQ mRNA were measured in 38, 29, and 10 patients, respectively. DeltaC(t) (median and range) values for NOP and MOP were 10.9 (7.8-13.7) and 16.0 (12.3-18.9), respectively, representing low expression of MOP and approximately 34-fold more NOP. MOP mRNA was not detected in seven samples and with DeltaC(t) values of approximately 20, ppN/OFQ was considered absent. When patients were grouped into normal (>50%) and impaired (<50%) LVEF, there was no difference between the groups for either NOP or MOP. In some patients, intraoperative LVEF was estimated using transoesophageal echocardiography, and there was no correlation with either NOP or MOP. CONCLUSIONS: The human right atrium of patients with coronary artery disease and heart failure expresses mRNA encoding NOP and possibly low levels of MOP. This does not correlate with degree of cardiac dysfunction. In addition, the atrium does not express ppN/OFQ mRNA.

The inhaled pin inaccessible to the bronchoscope: a management conundrum.

OBJECTIVE: The inhaled sharp foreign body is usually amenable to bronchoscopic extraction. When this fails, management poses a challenge. We present a logical approach to the inhaled pin inaccessible to the bronchoscope. CASE REPORT: A 12-year-old girl presented to the accident and emergency unit after accidentally inhaling a pin. Multiple attempts with both rigid and flexible bronchoscopy failed to access the pin, which had lodged distally in the anteromedial basal segment of the left lung. Eventually, the pin was extracted at thoracotomy. CONCLUSION: We discuss the reasons for extracting such pins, as opposed to leaving them in situ, and when to proceed from endoscopy to open surgery. Such knowledge is useful, not only to guide the multidisciplinary team in their combined approach to this unique challenge, but also to explain to the patient the rationale for the proposed treatment protocol.

Urotensin II receptor expression in human right atrium and aorta: effects of ischaemic heart disease.

BACKGROUND: Urotensin II (UII) and its receptor UT are involved in control of the cardiovascular system and are implicated in heart failure. We measured UT expression by quantitative PCR (Q-PCR) in atrial and aortic tissue, and plasma UII while simultaneously assessing cardiac function in 40 patients undergoing coronary artery bypass surgery. METHODS: RNA extracted from atrial and aortic samples was probed with specific Q-PCR UT and housekeeper (glyceraldehyde-3-phosphate dehydrogenase, GAPDH) TaqMan primers. Plasma UII was measured using radioimmunoassay. Left ventricular ejection fraction (LVEF) was measured using preoperative trans-thoracic echocardiography and ventriculography, and intraoperatively using transoesophageal echocardiography. Q-PCR data are expressed as difference in cycle threshold (DeltaC(t)=C(tUT)-C(tGAPDH): high number indicates low expression). RESULTS: There was no difference in DeltaC(t) in either atrium or aorta between patients with normal (LVEF >50%) or those with impaired (LVEF <50%) preoperative systolic function. There was a weak negative correlation (r(2)=0.245, P=0.031) between intraoperative LVEF and DeltaC(t) in 19 patients possibly indicating down-regulation of UT with worsening LVEF. Atria expressed significantly more UT than aorta (P=0.011). In the absence of non-diseased controls, plasma UII was higher than a historical control group. CONCLUSIONS: This is the first study to simultaneously measure UT (mRNA), UII, and cardiovascular function. Collectively, these pilot data may suggest a down-regulation of UT within the right atrium of patients with heart failure.

High transvalvular pressure gradients on intraoperative transesophageal echocardiography after aortic valve replacement: what does it mean?

Intraoperative transesophageal echocardiography is now used routinely during aortic valve replacement, allowing immediate evaluation of replaced or repaired valves. It is well recognised that high transvalvular pressure gradients can be detected immediately after implantation of a prosthetic aortic valve which may be due to multifactorial confounding variables, including functional phenomena, pressure recovery and prosthesis-patient mismatch. This review article explores the variety of methods available for assessing prosthetic aortic valve function and considers causative factors which may contribute to high transvalvular gradients in an attempt to determine whether a physical problem with the valve exists, or whether the valve is functioning normally.