The morbidity and mortality outcomes of indigenous Australian peoples after isolated coronary artery bypass graft surgery: the influence of geographic remoteness.

BACKGROUND: Though Indigenous Australian peoples reportedly have poorer survival outcome after cardiac surgery, few studies have jointly documented the experience of major morbidity, and considered the influence of patient geographic remoteness. METHODS: From January 1998 to September 2008, major morbidity events and survival were recorded for 2748 consecutive patients undergoing coronary artery bypass graft surgery. Morbidity and survival analyses adjusted for propensity deciles based on patient ethnicity and age, sex, left ventricular ejection fraction, recent myocardial infarction, tobacco smoking, diabetes, renal disease and history of stroke. Sensitivity analyses controlled for the patient accessibility/remoteness index of Australia (ARIA). RESULTS: The 297 Indigenous Australian patients (10.8% of total) had greater odds for total morbidity (adjusted odds ratio = 1.55; 95% confidence interval [CI] 1.04-2.30) and prolonged ventilation (adjusted odds ratio = 2.08; 95% confidence interval [CI] 1.25-3.44) in analyses adjusted for propensity deciles and geographic remoteness. With a median follow-up of 7.5 years (interquartile range 5.2-10.2), Indigenous Australian patients were found to experience 30% greater mortality risk (unadjusted hazard ratio = 1.30; 95% CI: 1.03-1.64, p = 0.03). The effect size strengthened after adjustment for propensity score (adjusted hazard ratio = 1.49; 95% CI: 1.13-1.96, p = .004). Adjustment for ARIA categorisation strengthened the effect size (adjusted HR = 1.54 (95% CI: 1.11-2.13, p = .009). CONCLUSION: Indigenous Australian peoples were at greater risk for prolonged ventilation and combined morbidity outcome, and experienced poorer survival in the longer term. Higher mortality risk among Indigenous Australians was evident even after controlling for remoteness and accessibility to services.

Oxygenator safety evaluation: a focus on connection grip strength and arterial temperature measurement accuracy.

This report describes the assessment of three specific safety-related specifications in the consideration of an alternate oxygenator; first the grip strength relationship between various oxygenator connectors and SMARxT tubing, second, the grip strength of various biopassive tubings and an isolated SMARxT connector, and finally, the accuracy of the arterial outlet temperature measurement. Grip strength experiments for the connections between the SMARxT tubing and the venous reservoir outlet and the oxygenator venous inlet and oxygenator arterial outlet of the Medtronic Affinity, Sorin Synthesis, Sorin Primox, and Terumo Capiox RX25 oxygenators were performed. In addition we compared the grip strength of polyvinyl chloride, Physio, Trillium, Carmeda, X-Coating, and SMARxT tubing. The accuracy of the integrated arterial outlet temperature probes was determined by comparing the temperatures measured by the integrated probe with a precision reference thermometer. Connector grip strength comparisons for the evaluation oxygenators with SMARxT tubing showed significant variation between oxygenators and connections (p = .02). Evaluation of the arterial outlet showed significant variation between evaluation oxygenators, while at the venous reservoir outlet and oxygenator inlet, there were no significant differences. Grip strength comparison data for the various tubing types demonstrated a main effect for tubing type F(5, 18) = 8.01, p = .002, eta(p)(2) = .77. Temperature accuracy measurements demonstrated that all oxygenators overread the arterial outlet temperature at 15 degrees C, whilst at temperatures > or = 25 degrees C, all oxygenators underread the arterial outlet temperature. The integrity of SMARxT tubing connection is influenced by the connector type, and may decline over time, highlighting the importance to not consider interchanging components of the bypass circuit as inconsequential.

WallGen, software to construct layered cellulose-hemicellulose networks and predict their small deformation mechanics.

We understand few details about how the arrangement and interactions of cell wall polymers produce the mechanical properties of primary cell walls. Consequently, we cannot quantitatively assess if proposed wall structures are mechanically reasonable or assess the effectiveness of proposed mechanisms to change mechanical properties. As a step to remedying this, we developed WallGen, a Fortran program (available on request) building virtual cellulose-hemicellulose networks by stochastic self-assembly whose mechanical properties can be predicted by finite element analysis. The thousands of mechanical elements in the virtual wall are intended to have one-to-one spatial and mechanical correspondence with their real wall counterparts of cellulose microfibrils and hemicellulose chains. User-defined inputs set the properties of the two polymer types (elastic moduli, dimensions of microfibrils and hemicellulose chains, hemicellulose molecular weight) and their population properties (microfibril alignment and volume fraction, polymer weight percentages in the network). This allows exploration of the mechanical consequences of variations in nanostructure that might occur in vivo and provides estimates of how uncertainties regarding certain inputs will affect WallGen's mechanical predictions. We summarize WallGen's operation and the choice of values for user-defined inputs and show that predicted values for the elastic moduli of multinet walls subject to small displacements overlap measured values. "Design of experiment" methods provide systematic exploration of how changed input values affect mechanical properties and suggest that changing microfibril orientation and/or the number of hemicellulose cross-bridges could change wall mechanical anisotropy.

Perfusion Downunder Collaboration Database--data quality assurance: towards a high quality clinical database.

Maintaining a high quality clinical database is critical to obtain reliable information upon which to base clinical and institutional decisions, and to preserve the public and the user's confidence in the quality of the data. The success of the Perfusion Downunder Collaboration (PDUC) Database, a dataset for cardiopulmonary bypass procedures, can only be guaranteed through the assurance of the quality of its data. This paper presents the evaluation of the data quality in the PDUC Database. Three participating centers located in Adelaide, Australia were audited: Flinders Private Hospital (FPH), Flinders Medical Center (FMC), and Ashford Hospital (AH). Ten perCent of the cases submitted from the first year of data harvest were audited (2008: FPH and FMC, 2009: AH). A total of 57 variables were reviewed and rates of discrepancies (inaccurate, missing, not entered, cannot be validated) categorized as 0-25%, 25-50%, 51-75%, and 75-100% of cases (% = cases with discrepancy/total cases audited) evaluated. Sixty randomly selected cases were audited, comprising of 13 cases from FPH, 31 cases from FMC, and 16 cases from AH. Of a total of 3420 data points evaluated, 6.9% were found to be inaccurate and 3.2% were missing. For each participating center, the great majority of variables have discrepancies in few (0-25%) of the cases audited. The discrepancies found can be attributed to systematic errors (e.g., error in date difference calculation for length of stays, data transformation error for postoperative dialysis) and random errors (e.g., use of incorrect unit for creatinine, transcription error for discharge date). The PDUC Database is currently reasonably accurate and complete. This evaluation is part of a complex system of data quality assurance, and when conducted routinely, could provide a continuous feedback loop towards a high quality PDUC Database.

In vitro evaluation of gaseous microemboli handling of cardiopulmonary bypass circuits with and without integrated arterial line filters.

The delivery of gaseous microemboli (GME) by the cardiopulmonary bypass circuit should be minimized whenever possible. Innovations in components, such as the integration of arterial line filter (ALF) and ALFs with reduced priming volumes, have provided clinicians with circuit design options. However, before adopting these components clinically, their GME handling ability should be assessed. This study aims to compare the GME handling ability of different oxygenator/ALF combinations with our currently utilized combination. Five commercially available oxygenator/ALF combinations were evaluated in vitro: Terumo Capiox SX25RX and Dideco D734 (SX/D734),Terumo Capiox RX25R and AF125 (RX/AF125), Terumo FX25R (FX), Sorin Synthesis with 102 microm reservoir filter (SYN102), and Sorin Synthesis with 40 microm reservoir filter (SYN40). GME handling was studied by introducing air into the venous return at 100 mL/min for 60 seconds under two flow/ pressure combinations: 3.5 L/min, 150 mmHg and 5 L/min, 200 mmHg. Emboli were measured at three positions in the circuit using the Emboli Detection and Classification (EDAC) Quantifier and analyzed with the General Linear Model. All circuits significantly reduced GME. The SX/D734 and SYN40 circuits were most efficient in GME removal whilst the SYN102 handled embolic load (count and volume) least efficiently (p < .001). A greater number of emboli <70 microm were observed for the SYN102, FX and RX/AF125 circuits (p < .001). An increase in embolic load occurred with higher flow/pressure in all circuits (p < .001). The venous reservoir significantly influences embolic load delivered to the oxygenator (p < .001). The majority of introduced venous air was removed; however, significant variation existed in the ability of the different circuits to handle GME. Venous reservoir design influenced the overall GME handling ability. GME removal was less efficient at higher flow and pressure, and for smaller sized emboli. The clinical significance of reducing GME requires further investigation.

Improving cardiopulmonary bypass: does continuous blood gas monitoring have a role to play?

The CDI 500 (Terumo Cardiovascular Systems, Ann Arbor, MI) is an in-line blood gas monitoring device that has been used in clinical practice for over a decade. Few randomized studies have evaluated the value of this device with respect to improved perfusion management. We routinely use automated continuous quality indicator programs to assess perfusion management. The aim of this study is to investigate in a prospective randomized trial the role of in-line blood gas monitoring in the improvement of blood gas management during cardiopulmonary bypass (CPB) utilizing continuous quality indicators. Patients were randomized into two groups (Control, CDI). Patients in the Control group received our standard CPB blood gas management, with intermittent blood gas results. Continuous blood gas measurements from the CDI 500 were recorded at 20-second intervals, with the perfusionist blinded to these measurements. Patients in the CDI group received standard CPB blood gas management, in addition to continuous blood gas measurements visible on the CDI 500, the alarm system activated, and the data recorded. Perfusion management for all cases was guided by institutional protocols. One hundred patients (50 in each group) were included in the study. No significant difference existed between the groups on demographic, surgical, or clinical outcomes. Blood gas levels of patients in the CDI group were able to be maintained in accordance to protocol a greater percentage of the time, e.g., pCO2 management was 2% versus 20% (p = .008); this was most notable for differences between the Control and the CDI group for pCO2 > 45 mmHg (p = .003). Practice variation determined via statistical control charts improved for both pH and pCO2, represented by a decrease in the variation associated with practice. Continuous blood gas monitoring with the CDI 500 results in significantly improved blood gas management as determined by adherence to institutional protocols.

Australian and New Zealand perfusion survey: management and procedure.

In this report, we will discuss management and procedural aspects of perfusion practice. This report allows us to compare and contrast recent trends and changes in perfusion with historic practices. A survey comprised of 233 single-answer and 12 open-ended questions was sent by e-mail to senior perfusionists or individuals in charge of perfusion in 40 hospital groups. The survey encompasses a review of the perfusion practices for the calendar year of 2003, and respondents were required to answer the survey based on the predominant practice in their institutions. Standard management of routine adult cardiopulmonary bypass (CPB) in 2003 consisted of perfusion strategies that achieved a target temperature of 32.0 degrees C (range, 28.0-35.0 degrees C), a flow index of 2.4 L/min/m2 (range, 1.6-3.0 L/min/m2) during normothermia and 1.8 L/min/m2 (range, 1.2-3.0 L/min/m2) during hypothermia, and a pressure during CPB between 50 (range, 30-65 mmHg) and 70 mmHg (range, 60-95 mmHg). Myocardial protection with blood cardioplegia was used in 77% of the 20,688 CPB cases, whereas in 53% cases, cardiotomy blood was never processed. Pre-operatively, 76% of perfusion groups assessed their patients (21% directly with the patient), and 85% responded that perfusionists performed or participated in a formal pre-bypass checklist. The majority of the perfusion groups used a handwritten perfusion record (62%), 12% used an electronic perfusion record, and 26% used both, whereas more than one half of the groups were involved in quality assurance (79%), incident reporting (74%), audits (62%), research (53%), participating in interdisciplinary meetings (53%), and morbidity and mortality meetings (65%). Only 26% conducted formal perfusion team meetings. This report outlines the status of clinical management and procedural performance for perfusion practices in Australia and New Zealand in 2003. Awareness of these trends will allow perfusionists to assess both individual practices and unit performance.

Concerted molecular displacements in a thermally-induced solid-state transformation in crystals of DL-norleucine.

Martensitic transformations are of considerable technological importance, a particularly promising application being the possibility of using martensitic materials, possibly proteins, as tiny machines. For organic crystals, however, a molecular level understanding of such transformations is lacking. We have studied a martensitic-type transformation in crystals of the amino acid DL-norleucine using molecular dynamics simulation. The crystal structures of DL-norleucine comprise stacks of bilayers (formed as a result of strong hydrogen bonding) that translate relative to each other on transformation. The simulations reveal that the transformation occurs by concerted molecular displacements involving entire bilayers rather than on a molecule-by-molecule basis. These observations can be rationalized on the basis that at sufficiently high excess temperatures, the free energy barriers to concerted molecular displacements can be overcome by the available thermal energy. Furthermore, in displacive transformations, the molecular displacements can occur by the propagation of a displacement wave (akin to a kink in a carpet), which requires the molecules to overcome only a local barrier. Concerted molecular displacements are therefore considered to be a significant feature of all displacive transformations. This finding is expected to be of value toward developing strategies for controlling or modulating martensitic-type transformations.

An approach to developing a force field for molecular simulation of martensitic phase transitions between phases with subtle differences in energy and structure.

d,l-Norleucine is one of only a few molecules whose crystals exhibit a martensitic or displacive-type phase transformation where the emerging phase shows a topotaxial relationship with the parent phase. The molecular mechanism for such phase transformations, particularly in molecular crystals, is not well understood. Crystalline phases that exhibit displacive phase transitions tend to be very similar in structure and energy. Consequently, the development of a force field for such phases is challenging as the phase behavior is determined by subtle differences in their lattice energies and entropies. We report an approach for developing a force field for such phases with an application to d,l-norleucine. The proposed procedure includes calculation of the phase diagram of the crystalline phases as a function of temperature to identify the best force field. d,l-Norleucine also presents an additional problem since in the solid state it exists as a zwitterion that is unstable in vacuo and therefore cannot be characterized using high-level ab initio calculations in the gas phase. However, a stable zwitterion could be obtained using Onsager's reaction-field continuum model for a solvent (SCRF) using both Hartree-Fock and density functional theory. A number of force fields and the various sets of partial charges obtained from the SCRF calculations were screened for their ability to reproduce the crystal structures of the two known phases, alpha and beta, of d,l-norleucine. Selected parameter sets were then employed in free energy minimizations to identify the best set on the basis of a correct prediction of the alpha-beta phase transition. The Williams' nonbonded parameters combined with partial charges from SCRF-Polarized Continuum Model calculation were found to reproduce the structures of the phases accurately and also maintained their stability in extended molecular dynamics simulations in the Parrinello-Rahman constant stress ensemble. Moreover, we were also able to successfully simulate the phase transformation of the beta- to the alpha-phase. The identified force field should enable detailed studies of the phase transformations exhibited by crystals of d,l-norleucine and hence enhance our understanding of martensitic-type transformations in molecular crystals.