Electrospun Metal-Organic Framework-Fabric Nanocomposites as Efficient Bactericides.

In this work, we utilized electrospinning to develop advanced composite membranes of polyvinyl chloride (PVC) loaded with postmetalated metal-organic frameworks (MOFs), specifically UiO-66(COOH)2-Ag and ZIF-8-Ag. This innovative technique led to the creation of highly stable PVC/MOFs-Ag membrane composites, which were thoroughly characterized using various analytical techniques, including scanning electron microscopy, powder X-ray diffraction, thermogravimetric analysis, X-ray photoelectron spectroscopy, porosity analysis, and water contact angle measurement. The results verified the successful integration of MOF crystals within the nanofibrous PVC membranes. The obtained composites exhibited larger fiber diameters for 5 and 10% MOF loadings and a smaller diameter for 20% loading. Additionally, they displayed greater average pore sizes than traditional PVC membranes across most MOF loading percentages. Furthermore, we examined the antibacterial properties of the fabricated membranes at different MOFs-Ag loadings. The findings revealed that the membranes demonstrated significant antibacterial activity up to 95% against both Gram-negative (Escherichia coli) and Gram-positive (Staphylococcus aureus) bacteria as the MOFs-Ag loading increased, even when maintaining a constant silver concentration. This indicates a contact-based inhibition mechanism. The outcomes of this study have crucial implications for the development of novel, stable, and highly effective antibacterial materials, which could serve as superior alternatives for face masks and be integrated into materials requiring regular decontamination, as well as potential water filtration systems.

Association Between High-Density Lipoprotein Cholesterol Levels and Adverse Cardiovascular Outcomes in High-risk Populations.

Importance: Previous studies have shown lower cardiovascular risk with higher high-density lipoprotein cholesterol (HDL-C) levels. However, recent data in the general population have shown increased risk of adverse outcomes at very high HDL-C concentrations. Objective: To study the association between very high HDL-C levels (>80 mg/dL) and mortality in patients with coronary artery disease (CAD) and to investigate the association of known HDL-C genotypes with high HDL-C level outcomes. Design, Setting, and Participants: This prospective, multicenter, cohort study, conducted from 2006 to present in the UK and from 2003 to present in Atlanta, Georgia, recruited patients with CAD from the UK Biobank (UKB) and the Emory Cardiovascular Biobank (EmCAB), respectively. Patients without confirmed CAD were excluded from the study. Data analyses were conducted from May 10, 2020, to April 28, 2021. Exposure: High HDL-C levels (>80 mg/dL). Main Outcomes and Measures: The primary outcome was all-cause death. The secondary outcome was cardiovascular death. Results: A total of 14 478 participants (mean [SD] age, 62.1 [5.8] years; 11 034 men [76.2%]) from the UKB and 5467 participants (mean [SD] age, 63.8 [12.3] years; 3632 men [66.4%]) from the EmCAB were included in the study. Over a median follow-up of 8.9 (IQR, 8.0-9.7) years in the UKB and 6.7 (IQR, 4.0-10.8) years in the EmCAB, a U-shaped association with outcomes was observed with higher risk in those with both low and very high HDL-C levels compared with those with midrange values. Very high HDL-C levels (>80 mg/dL) were associated with increased risk of all-cause death (hazard ratio [HR], 1.96; 95% CI, 1.42-2.71; P < .001) and cardiovascular death (HR, 1.71; 95% CI, 1.09-2.68; P = .02) compared with those with HDL-C levels in the range of 40 to 60 mg/dL in the UKB after adjustment for confounding factors. These results were replicated in the EmCAB. These associations persisted after adjustment for the HDL-C genetic risk score within the UKB. Sensitivity analyses demonstrated that the risk of all-cause mortality in the very high HDL-C group was higher among men than women in the UKB (HR, 2.63; 95% CI, 1.75-3.95; P < .001 vs HR, 1.39; 95% CI, 0.82-2.35; P = .23). Conclusions and Relevance: Results of this cohort study suggest that very high HDL-C levels are paradoxically associated with higher mortality risk in individuals with CAD. This association was independent of the common polymorphisms associated with high HDL-C levels.

Usefulness of Restless Legs Symptoms to Predict Adverse Cardiovascular Outcomes in Men With Coronary Artery Disease.

The relationship between restless legs syndrome (RLS) and cardiovascular disease remains enigmatic in the general population, and its prognostic value in patients with coronary artery disease (CAD) is unknown. In this study, the frequency of RLS-like symptoms was assessed using a validated instrument in 3,266 patients undergoing cardiac catheterization (mean age 64 years, 62% male, 23% Black, and 74% with obstructive CAD). Patients were followed for primary end points of cardiovascular death or incident myocardial infarction. Fine and Gray hazard models explored the association between RLS and incident events after adjustment for demographic and clinical risk factors. In the total cohort, 29% of patients reported mild (rare or sometimes) symptoms, and 15% of patients had moderate/severe (often to almost always) symptoms of RLS. Female sex (odds ratio [OR] 2.11, 95% confidence interval (CI), 1.68 to 2.57), body mass index (OR 1.12 per 5 kg/m2, 95% CI, 1.04 to 1.22), diabetes (OR 1.43, 95%,1.15 to 1.79), and ß-blocker use (OR 1.35, 95% CI, 1.07 to 1.72) were independently associated with moderate/severe symptoms of RLS compared with no symptoms. Over a 5-year follow-up period, 991 patients suffered an adverse event. Compared with those with no symptoms, patients with moderate/severe RLS had significantly higher risk of the primary end point (hazard ratio [HR] = 1.33, 95%),CI 1.01 to 1.76) after adjustment for demographic and clinical risk factors. The association was more significant in men than women, HR 1.98, 95% CI, 1.41 to 2.78 versus HR 0.99 (,95% CI, 0.64 to 1.52, p interaction= 0.013. In conclusion, among men with CAD, moderate-to-severe symptoms of RLS are associated with significantly higher risk of adverse cardiovascular outcomes, independent of traditional risk factors.

Nonsteroidal Anti-inflammatory Drugs and Cardiovascular Risk in American Football.

INTRODUCTION: Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with adverse cardiovascular outcomes and reportedly overused in American-style football (ASF). However, assessment of ASF NSAID use in the context of cardiovascular risk has not been performed. We sought to characterize NSAID use patterns and the association with cardiovascular risk in a diverse cohort of high school and collegiate ASF athletes. METHODS: A total of 226 ASF athletes, 60 endurance athletes, and 63 nonathletic controls were studied pre- and postseason with echocardiography, vascular applanation tonometry, and clinical data assessment. Qualitative NSAID use throughout the season was recorded at postseason. RESULTS: ASF athletes gained weight (Δ0.86 ± 3.9 kg, P < 0.001), increased systolic blood pressure (SBP, Δ3.1 ± 12 mm Hg, P < 0.001) and pulse wave velocity (Δ0.2 ± 0.6 m·s, P < 0.001), and decreased E' (Δ-1.4 ± 2.8 cm·s, P < 0.001) across one athletic season. Seventy-seven percent (n = 173) of ASF athletes reported that sport-specific NSAID use began in middle school. ASF NSAID use was more frequent with "weekly" (n = 42.19%) and "daily" (n = 32.14%) use compared with endurance athletes (P < 0.001) and controls (P = 0.02). ASF NSAID use increased in parallel with postseason SBP and weights. "Daily" ASF NSAID users demonstrated the highest postseason SBP (137 ± 13 vs 128 ± 13 mm Hg, P = 0.002) and weight (109.0 ± 18.6 vs 95.8 ± 20.5 kg, P = 0.002) compared with "never/rare" users. Adjusting for player position, SBP, pulse wave velocity, and E', increased weight (odds ratio = 1.04, 95% confidence interval = 1.0-1.08, P = 0.037) was associated with more frequent NSAID use. CONCLUSIONS: Habitual NSAID use commonly begins during adolescence, before full physical maturation, and is associated with cardiovascular risk, particularly increased weight, in ASF athletes. NSAID use frequency should be considered when risk stratifying high-risk ASF athletes.

Bilateral Carotid Patch Infection Occurring 12 years Following Endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) is the most commonly used invasive procedure for treatment of carotid stenosis. Different methods are used to close the arteriotomy including primary closure and patch repair with a graft. Prosthetic patch infection is a rare but serious complication of patch closure, and we will present a unique case of carotid patch infection (CPI) 12 years after implantation. CASE: Patient is 76-year-old male ex-smoker with history of bilateral CEA with Dacron patch closure 12 years prior to presentation. He had a left neck draining sinus one year prior to presentation that was treated by patch excision and ICA ligation. He presented to us one year later with a right neck draining sinus tract, reaching the carotid sheath on CT scan. Surgery was done under EEG and NIRS oximetry with shunting. Excision of the patch with the involved ICA was done. CCA to distal ICA bypass was done by a reversed GSV graft. Intraoperative cultures of the patch grew Staphylococcus species coagulase negative, so the patient was discharged on antibiotics for one month. The patient had early postoperative swallowing difficulty that resolved over six weeks but no other complications. Patient was followed-up every three months and he was doing well on one-year follow-up. DISCUSSION: Carotid patch infection is a well-documented complication of CEA with a prevalence between 0.27% and 1%. It most commonly presents as a pseudoaneurysm, draining sinus or neck swelling. The highest incidence is during the first year after the operation, and especially within the first three months postop due to contamination or wound infections; however, late presentations such as our case are rare. Bacterial cultures are positive in around 80% of the cases, growing mostly gram-positive cocci. Other organisms include Pseudomonas and Enterobacter. Management of CPI is challenging; difficulties include distal ICA control, friable arteries and adhesions to cranial nerves. Debridement with ligation of the vessel stump is an option, but may not be tolerated. Best outcomes are obtained with autogenous revascularization after debridement as was done in our case on the right side. Newer endovascular techniques may provide alternatives in urgent or high-risk situations, especially as staged procedures. This case is unique in its bilaterality and the longest time till presentation in the literature.

Weight Gain, Hypertension, and the Emergence of a Maladaptive Cardiovascular Phenotype Among US Football Players.

Importance: Former US football athletes are at increased risk of cardiovascular (CV) morbidity and mortality compared with the general population and other professional athletes. However, responsible maladaptive CV phenotypes have not been fully characterized. Objective: To address the emergence and progression of multiple independent factors associated with CV risk across serial years of collegiate US football participation. Design, Setting, and Participants: Collegiate US football athletes from 2 National Collegiate Athletic Association Division I programs were recruited as freshmen between June 2014 and June 2017 and analyzed at multiple points throughout 3 complete years of collegiate US football participation (until January 2019). Excluded athletes were those who did not complete any season of US football training because of injury, illness, or leaving the team. Factors associated with CV risk assessed clinically, by transthoracic echocardiography, and by vascular applanation tonometry were recorded. Exposures: The exposure of interest was seasonal US football exposure, including training, competition, and the training environment. Main Outcomes and Measures: Primary outcome measures were left ventricular mass index and geometry (cardiac structure), early diastolic myocardial relaxation velocity (E'; diastolic function), and pulse-wave velocity (arterial stiffness). Results: Of 186 individuals recruited as freshmen, 126 athletes were included in analyzed data. Collegiate US football athletes (62 white individuals [49%]; 63 black individuals [50%]; 77 nonlinemen [61%]; 49 linemen [39%]; 126 male individuals [100%]) weighed a mean (SD) of 101.1 (21.0) kg, with a mean systolic blood pressure of 129.1 (11.6) mm Hg at baseline of the freshman season. Adjusting for race, height, and player position, there were significant increases in weight (mean [SE] Δ, 4.74 [0.6] kg; P < .001), systolic blood pressure (mean [SE] Δ, 11.6 [1.6] mm Hg; P < .001), and pulse-wave velocity (mean [SE] Δ, 0.24 [0.09] m/s; P = .007), and significant declines in E' (mean [SE] Δ, -1.7 [0.3] cm/s; P < .001) across 3 years of US football participation. Weight gain was associated with both arterial stiffening (increased pulse-wave velocity, ß = 0.01 [SE, 0.004]; P = .003) and the development of concentric left ventricular hypertrophy (odds ratio, 1.09 [95% CI, 1.05-1.14]; P < .001); increased systolic blood pressure was also associated with arterial stiffening (ß = 0.01 [SE, 0.003]; P = .007) and the development of concentric left ventricular hypertrophy (odds ratio, 1.04 [95% CI, 1.01-1.07]; P = .02). Conclusions and Relevance: Collegiate US football athletes who gain weight and develop increased systolic blood pressure levels are at risk for the development of a pathologic CV phenotype characterized by concentric left ventricular hypertrophy, arterial stiffening, and reduced left ventricular diastolic function. Future work aimed at optimizing CV health in this population, who are young but uniquely at risk, is warranted.

A novel system for automated propofol sedation: hybrid sedation system (HSS).

Closed-loop systems for propofol have been demonstrated to be safe and reliable for general anesthesia. However, no study has been conducted using a closed-loop system specifically designed for sedation in patients under spinal anesthesia. We developed an automatic anesthesia sedation system that allows for closed-loop delivery of propofol for sedation integrating a decision support system, called the hybrid sedation system (HSS). The objective of this study is to compare this system with standard practice. One hundred fifty patients were enrolled and randomly assigned to two groups: HSS-Group (N = 75), in which propofol was administered using a closed-loop system; Control Group (N = 75), in which propofol was delivered manually. The clinical performance of the propofol sedation control is defined as efficacy to maintain bispectral index (BIS) near 65. The clinical control was called 'Excellent', 'Good', 'Poor' and 'Inadequate' with BIS values within 10 %, from 11 to 20 %, 21 to 30 %, or greater than 30 % of the BIS target of 65, respectively. The controller performance was evaluated using Varvel's parameters. Data are presented as mean ± standard deviation, groups were compared using t test or Chi square test, P < 0.05. Clinical performance of sedation showed 'Excellent' control in the HSS-group for a significantly longer period of time (49 vs. 26 % in the control group, P < 0.0001). 'Poor' and 'Inadequate' sedation was significantly shorter in the HSS Group compared to the Control Group (11 and 10 % vs. 20 and 18 %, respectively, P < 0.0001). The novel, closed-loop system for propofol sedation showed better maintenance of the target BIS value compared to manual administration.

Robotics and regional anesthesia.

PURPOSE OF REVIEW: Robots in regional anesthesia are used as a tool to automate the performance of regional techniques reducing the anesthesiologist's workload and improving patient care. The purpose of this review is to show the latest findings in robotic regional anesthesia. RECENT FINDINGS: The literature separates robots in anesthesia into two groups: pharmacological robots and manual robots. Pharmacological robots are mainly closed-loop systems that help in the titration of anesthetic drugs to patients undergoing surgery. Manual robots are mechanical robots that are used to support or replace the manual gestures performed by anesthesiologists. Although in the last decade researchers have focused on the development of decision support systems and closed-loop systems, more recent evidence supports the concept that robots can also be useful in performing regional anesthesia techniques. SUMMARY: Robots can improve the performance and safety in regional anesthesia. In this review, we present the developments made in robotic and automated regional anesthesia, and discuss the current state of research in this field.

A technical description of a novel pharmacological anesthesia robot.

To control the three components of general anesthesia (hypnosis, analgesia, and neuromuscular blockade), an automated closed-loop, anesthesia-drug delivery system (McSleepy) was developed. Bispectral index was used as the control variable for hypnosis, the analgoscore for analgesia, and phonomyography for neuromuscular blockade. McSleepy can be used to control the induction, maintenance and emergence from general anesthesia. To do so, a large touch screen is used to provide a user friendly interface, permitting bidirectional communication: the user giving information about the different stages of anesthesia, and the system prompting the anesthesiologist to perform certain actions such as mask ventilation, intubation or waking-up the patient using audio clips with voice commands. Several safety features were implemented to provide a secure and reliable anesthesia. Preliminary results of 15 patients are presented in this paper. Evaluation of McSleepy was done through an assessment of its clinical performance and using Varvel's performance indices. The system was found to be clinically useful by providing good precision in drug administration and reliable results for the duration of a general anesthesia.

Use of a decision support system improves the management of hemodynamic and respiratory events in orthopedic patients under propofol sedation and spinal analgesia: a randomized trial.

Decision support systems (DSSs) have been successfully implemented into clinical practice offering clinical suggestions and treatment options with excellent results in various clinical settings. Although their results appeared promising, showing that DSSs can increase anesthesiologists' vigilance and patient safety during surgery, DSSs have never been used before to help anesthesiologists in identifying critical events in patients under spinal analgesia with sedation. We have developed and clinically evaluated a DSS for this specific task. The DSS was developed with the ability to indicate respiratory and hemodynamic critical events via audio-visual alarms and give decisional aid. Critical respiratory events were defined as SpO2 <92 % and/or respiratory rate <8/min. Critical hemodynamic events were defined as mean arterial pressure (MAP) <60 mmHg and/or heart rate <40 bpm. The objective of this trial was to determine the duration to detect and treat these critical events with the help of the DSS (DSS Group) compared with a standard Control Group where the system was not in place. One hundred and fifty orthopedic patients undergoing spinal analgesia with propofol sedation were enrolled in this randomized control trial, 75 each group. All respiratory and hemodynamic critical events were detected in the DSS Group, while in the Control Group 26 % of the events were not detected.The delay to detect and treat critical events was significantly shorter (P < 0.0001) in the DSS Group at 9.1 ± 3.6 s, whereas 27.5 ± 18.9 s were necessary to identify them in the Control Group. There were no significant differences in physiological parameters in the two groups during surgery. The number of critical events/h occurring and the duration of surgery were similar in both groups. The number of hypoxemia episodes was significantly less (P = 0.036) in the DSS group (0.7 ± 1.0 vs. 1.4 ± 2.2 for the Control Group). The DSS tested in this trial could help the clinician to detect and treat critical events more efficiently and in a shorter length of time.

Technical communication: First robotic ultrasound-guided nerve blocks in humans using the Magellan system.

BACKGROUND: Ultrasound-guided nerve blocks are becoming a standard of modern anesthesia. We developed a robotic system, Magellan, to perform nerve blocks using a remote control center. METHODS: Thirteen patients were enrolled in this pilot study. The Magellan system consists of 3 main components: a joystick, a robotic arm, and a software control system. The joystick allows simulation of wrist or arm movements of the proceduralist. After localization of the sciatic nerve, 35 mL of bupivacaine 0.25% was injected. The success rate of sciatic nerve blocks and block performance times (performance time=interval of time from the start of the ultrasound search for the nerve to the end of the injection of the drug; robotic time=interval of time from the identification of the nerve to the end of the injection of the drug) were determined. Data are presented as median (25th, 75th; minimal, maximal) and categorical data. RESULTS: Eight men and 5 women aged 34 years were included in this study. Nerve blocks were successful in all patients. A successful attempt was defined as the introduction of the needle into the nerve sheath; motor or sensory block was not used to determine the success rate. The nerve performance time was 189 seconds (150, 233; 90, 305), whereas the robotic time was 164 seconds (121, 210; 73, 271). CONCLUSIONS: We present the first human testing of a robotic ultrasound-guided nerve block system. The success rate was 100%. The total performance time was approximately 3 minutes to 4 minutes.

The Kepler intubation system.

Our goal in this study was to develop a robotic intubation system and to conduct a feasibility pilot study on the use of a robotic intubation system for endotracheal intubations. The Kepler Intubation System was developed, consisting of a remote control center (joystick and intubation cockpit) linked to a standard videolaryngoscope via a robotic arm. Ninety intubations were performed by the Kepler Intubation System on an airway trainer mannequin by a single operator. The first group of 30 intubations was performed with the operator in direct view of the mannequin (direct view group). The second group of 30 intubations was performed with the operator unable to see the mannequin (indirect view group). Thirty semiautomated intubations were also performed during which the robotic system replayed a trace of a previously recorded intubation maneuver (semiautomated group). First-attempt success rates and intubation times for each trial were recorded. Trends were analyzed using linear regression. Data are presented as mean (SD). All intubations were successful at first attempt. The mean intubation times were 46 (18) seconds, 51 (19) seconds, and 41 (1) seconds for the direct view, indirect view, and semiautomated group, respectively. Both the direct and indirect view groups had a negative slope, denoting that each successive trial required less time. The semiautomated group had a slope of 0 and a low SD of 1 second, illustrating the high reproducibility of automated intubations. We concluded that a robotic intubation system has been developed that can allow remote intubations within 40 to 60 seconds.

Relaxofon: a neuromuscular blockade monitor for patients under general anesthesia.

Anesthesia consists of three components: unconsciousness, analgesia and neuromuscular blockade (NMB). A specific drug is administered by the anesthesiologist to control these different components. In this paper we propose a new system for monitoring the neuromuscular blockade in anesthesized patients during surgery. Neuromuscular blockade drugs are used routinely by clinicians to induce muscle relaxation in patients. However, the use of these drugs has some risks, so an adequate monitoring of the effects of these drugs is essential. This paper describes the Relaxofon, a NMB monitoring device based on phonomyography. The Relaxofon is composed of a hardware subsystem that records muscle sounds using microphones and a special circuit to filter out the noise and amplify the signal, and a software subsystem that analyses the acquired signal. We tested the ability of the system to record phonomyographic signals from the adductor pollicis and the corrugator supercilii muscles. We then performed the Bland-Altman test to compare the manual Train-of-Four ratio (a measure of the depth of muscle relaxation) calculation against the one performed by the Relaxofon. Finally, we calculated the Pearson correlation coefficient to measure the linear dependence between the two methods. Automatic Train-of-Four ratio calculations using this system showed very good agreement with manual calculations. Results from this work may ultimately lead to integration of NMB monitoring to an automated closed-loop anesthesia system.

Robotic anesthesia - a vision for the future of anesthesia.

This narrative review describes a rationale for robotic anesthesia. It offers a first classification of robotic anesthesia by separating it into pharmacological robots and robots for aiding or replacing manual gestures. Developments in closed loop anesthesia are outlined. First attempts to perform manual tasks using robots are described. A critical analysis of the delayed development and introduction of robots in anesthesia is delivered.