Abdominal Aortic Aneurysm in Heart Transplant Recipients: New Insights from a 30-year Experience at a Single Center.

BACKGROUND: The improvement in survival rates for heart transplant recipients (HTRs) has increased their risk of developing extracardiac diseases such as abdominal aortic aneurysms (AAAs). The purposes of this study were to evaluate the prevalence and to describe the clinical features and natural history of AAA in HTRs. METHODS: A retrospective review of all patients (375) who underwent heart transplantation (HT) at our center over a 32-year period (1983-2015) was carried out. RESULTS: We identified 20 patients (5.3%) with AAA. All but one patient were male (95%), and most of them (80%) had a history of ischemic heart disease (IHD) prior to transplantation. The mean age of the patients with AAA at transplant was 57.2 ± 7.3 years (range: 42-62 years). Seven of the 20 patients with AAA already had an AAA (30-55 mm) prior to transplantation. The average aneurysm size at the time of diagnosis was 40.9 ± 9.6 mm, and the average patient age at the time of diagnosis was 62.2 ± 8.3 years. The mean linear expansion rate was 10.6 ± 2.12 mm/y, and the exponential expansion rate was 0.220 ± 0.040 year-1, respectively. The median follow-up time was 5.4 years (range 0.1-27.4 years). The median survival was 143 months (95% confidence interval (CI) 65 to 180 months) for the 20 HTRs with AAA and 68.8 months (95% CI 46 to 88 months) for the other HTRs. CONCLUSIONS: The natural history of AAA in HTR is characterized by an increased expansion rate. Male HTR with end-stage IHD are particularly at risk and should be closely followed-up after HT.

UPTAKE OF 226RA FROM IRRIGATION WATER BY BASIL CROPS.

The transfer of 226Ra from irrigation water to basil crops was studied in field conditions. A dedicated basil plot was established and divided into test and control subplots irrigated with water having high (2.1 Bq L-1) and low (0.05 Bq L-1) activity concentrations of 226Ra, respectively. The experiment was performed over a period of 18 months during the autumn, winter and spring seasons, altogether eight cycles of growth and harvest. The activity concentration of 226Ra in basil grown in the test subplots was found to increase from a value of 0.6 Bq kg-1 up to 5.1 Bq kg-1 with successive cycles, compared to a mean value of 0.2 Bq kg-1 for basil grown in the control subplots. The increase in activity concentration of 226Ra in basil grown in the test subplots is mainly attributed to its build-up in the soil in which the level of 226Ra was found to increase by ~ 40%. The effective uptake of 226Ra from the irrigation water (via soil) by the basil plants was found to be approximately 0.4%. The maximal radiation dose following consumption of basil crops grown in the test subplots is negligible (~3 µSv/y).

Efficacy of the RemoweLL cardiotomy reservoir for fat and leucocyte removal from shed mediastinal blood: a randomized controlled trial.

INTRODUCTION: Re-transfusion of lipid particles and activated leucocytes with shed mediastinal blood (SMB) can aggravate cardiopulmonary bypass-associated inflammation and increase the embolic load. This study evaluated the fat and leucocyte removal capacity of the RemoweLL cardiotomy reservoir. METHODS: Forty-five patients undergoing elective on-pump cardiac surgery were randomly allocated to filtration of SMB using the RemoweLL or the Admiral cardiotomy reservoir. The primary outcome was a drop in leucocytes and lipid particles obtained with the two filters. The effect of the filters on other blood cells and inflammatory mediators, such as myeloperoxidase (MPO), was also assessed. RESULTS: The RemoweLL cardiotomy filter removed 16.5% of the leucocytes (p<0.001) while no significant removal of leucocytes was observed with the Admiral (p=0.48). The percentage reductions in lipid particles were similar in the two groups (26% vs 23%, p=0.2). Both filters similarly affected the level of MPO (p=0.71). CONCLUSION: The RemoweLL filter more effectively removed leucocytes from SMB than the Admiral. It offered no advantage in terms of lipid particle clearance.

Hydroxyethyl Starch 130/0.4 and the Risk of Acute Kidney Injury After Cardiopulmonary Bypass: A Single-Center Retrospective Study.

OBJECTIVES: To investigate whether using hydroxyethyl starch (HES) 130/0.4 as a pump prime and for intraoperative fluid therapy is associated with postoperative acute kidney injury (AKI) after adult cardiac surgery. DESIGN: Retrospective observational study. SETTING: University hospital, single center. PARTICIPANTS: Six hundred six adult patients who underwent on-pump cardiac surgery between April 2013 and June 2014 were included. INTERVENTIONS: Until July 2013, balanced HES 130/0.4 (Volulyte(®), Fresenius Kabi AG, Bad Homburg, Germany) was used both as a pump prime (1,500 mL) and for intraoperative fluid therapy (1,000 mL). From August 2013, HES was replaced entirely by a balanced crystalloid solution (Plasma-Lyte A, Baxter, Lessines, Belgium). MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the incidence of postoperative AKI during the first 48 postoperative hours, determined using the Acute Kidney Injury Network classification. Secondary outcomes included kidney function at postoperative day 7, postoperative dialysis or hemofiltration, postoperative pulmonary complications, lengths of intensive care unit and hospital stays, postoperative fluid balance and urinary output, surgical revision for bleeding, and 30-day mortality. Multivariable logistic regression was used to adjust for confounders. AKI occurred in 9.5% of crystalloid patients and in 21.5% of HES patients. Patients who received HES were about twice as likely to develop postoperative AKI as those treated with crystalloids (adjusted OR 2.26; 95% CI, 1.40-3.80; p = 0.02). HES patients also had a significantly more positive fluid balance and a lower urinary output during the first 48 postoperative hours. The incidence of surgical revision for bleeding was greater in the HES group (4.6% v 1.4%, p = 0.02). CONCLUSION: This study suggested that using balanced HES 130/0.4 as a pump prime and for intraoperative fluid therapy in adult patients undergoing on-pump cardiac surgery was associated with a greater incidence of AKI during the early postoperative period.

Incidence and outcomes of acute kidney injury after cardiac surgery using either criteria of the RIFLE classification.

BACKGROUND: Adult cardiac surgery is significantly associated with the development of acute kidney injury (AKI). Still, the incidence and outcomes of AKI vary according to its definition. Our retrospective monocentric study comparatively investigates the yield of RIFLE definition, which is based on the elevation of serum creatinine levels (SCr) or the reduction of urine output (UO), taking into account only one or both criteria. Pre- and per-operative risk factors for post-operative AKI were evaluated. METHODS: All adult patients undergoing cardiac surgery, with or without cardiopulmonary bypass, from April 2008 to March 2009 were included. Clinical, biological and surgical features were recorded. Baseline serum creatinine was determined as its value on day 7 before surgery. Post-operative AKI was diagnosed and scored based upon the highest serum creatinine and/or the lowest urine output. RESULTS: 443 patients (Male/Female ratio, 2.3; median age, 69y) were included, with 221 (49.9%) developing postoperative AKI. Elevated serum creatinine (AKISCr) and oliguria (AKIUO) was observed in 9.7% and 40.2%, respectively. AKI patients had a significantly higher BMI and baseline SCr. In comparison to AKIUO, AKISCr mostly occurred in patients with co-morbidities, and was associated with an increased mortality at 1-year post surgery. CONCLUSIONS: The use of standard RIFLE definition of AKI in a cohort of 443 patients undergoing cardiac surgery resulted in an incidence reaching 50%. Still, significant discrepancies were found between AKISCr and AKIUO regarding the incidence and outcomes. In line with previous reports, our data questions the utility of urine output as a criterion for AKI diagnosis and management after cardiac surgery.

The effect of intraoperative 6% balanced hydroxyethyl starch (130/0.4) during cardiac surgery on transfusion requirements.

OBJECTIVES: To compare transfusion requirements in adult cardiac surgery patients when balanced hydroxyethyl starches (HES) (130/0.4) or balanced crystalloids is used for pump prime and intraoperative fluid therapy. DESIGN: Data were obtained retrospectively from medical records and perfusion charts. Matching based on propensity scores was used to adjust for potential confounders. SETTING: A university hospital. PARTICIPANTS: Adult patients undergoing cardiac surgery with the use of cardiopulmonary bypass. INTERVENTIONS: Allocation to one of the study groups according to whether balanced HES or balanced crystalloids was used for pump prime and intraoperative fluid therapy. MEASUREMENTS AND MAIN RESULTS: 240 propensity-matched patients were retained for final analyses. Forty-eight patients (40%) of the colloid group and 28 patients (23.3%) of the crystalloid group received blood products, with an odd ratio (95% CI) of 2.1(1.2-3.8 (P=0.009). After bypass HES patients had lower hemoglobin levels (8.4 [1.3] gr/dL vs 9.6 [2] gr/dL; P<0.001) and a higher cumulative chest drain output after 3 hours (180 [210] mL vs 140 [100] mL, P<0.001]. Heparinase thromboelastogram (TEG®) showed longer K times (2.5[1.1] vs 1.6[0.8], P<0.001) and lower maximal amplitudes (55.1[12.5] vs 63.4[9.8], P=0.008). CONCLUSIONS: HES patients required more transfusions, owing to greater hemodilution, HES-induced clotting disturbances, and bleeding.

Listening to the nurse pays off: an integrated Nurse HealthLine programme was associated with significant cost savings.

AIM: To estimate the relationship between adherence to nurse recommendations about where to seek care and expenditures for health-care services received by callers to a Nurse HealthLine telephone-based triage programme. METHODS: Health-care utilization and claims data from callers to the Nurse HealthLine were included. Adherent callers were those who followed the nurse recommendations, while those who did not were classified as non-adherent. Programme-related savings were estimated using differences in downstream health-care expenditures between adherent and non-adherent callers after using multivariate modelling to adjust for between-group differences. RESULTS: Fifty-five per cent of callers were adherent. Nurses were over three times as likely (41% vs. 13%) to recommend seeking a higher level of care (e.g. emergency room vs. urgent care). Regression analyses showed that the impact of getting members to the appropriate place of care was associated with significant annual savings of $13.8 million (P < 0.05), attributable mostly to Medicare, generating a positive return on investment of $1.59. CONCLUSIONS: This is the first known Nurse HealthLine triage programme exclusively for Medicare beneficiaries with supplemental coverage. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers should consider promoting telephone-based triage programmes as complementary to clinical nursing, which has a direct impact on health-care utilization and costs.

Sustainable agricultural use of natural water sources containing elevated radium activity.

Relatively elevated concentrations of naturally occurring radium isotopes ((226)Ra, (228)Ra and (224)Ra) are found in two main aquifers in the arid southern part of Israel, in activity concentrations frequently exceeding the limits set in the drinking water quality regulations. We aimed to explore the environmental implications of using water containing Ra for irrigation. Several crops (cucumbers, melons, radish, lettuce, alfalfa and wheat), grown in weighing lysimeters were irrigated at 3 levels of (226)Ra activity concentration: Low Radium Water (LRW)<0.04 Bq L(-1); High Radium Water (HRW) at 1.8 Bq L(-1) and (3) Radium Enriched Water (REW) at 50 times the concentration in HRW. The HYDRUS 1-D software package was used to simulate the long-term (226)Ra distribution in a soil irrigated with HRW for 15 years. Radium uptake by plants was found to be controlled by its activity in the irrigation water and in the soil solution, the physical properties of the soil and the potential evapotranspiration. The (226)Ra apeared to accumulate mainly in the leaves of crops following the evapotranspiration current, while its accumulation in the edible parts (fruits and roots) was minimal. The simulation of 15 years of crop irrigation by HYDERUS 1-D, showed a low Ra activity concentration in the soil solution of the root zone and a limited downward mobility. It was therefore concluded that the crops investigated in this study can be irrigated with the natural occurring activity concentration of (226)Ra of 0.6-1.6 Bq L(-1). This should be accompanied by a continuous monitoring of radium in the edible parts of the crops.

Newborn screening 50 years later: access issues faced by adults with PKU.

Fifty years after the implementation of universal newborn screening programs for phenylketonuria, the first disease identified through newborn screening and considered a success story of newborn screening, a cohort of adults with phenylketonuria treated from birth provides valuable information about effects of long-term treatment for inborn errors of metabolism in general, and phenylketonuria specifically. For phenylketonuria, newborn screening allows early implementation of the phenylalanine-restricted diet, eliminating the severe neurocognitive and neuromotor impairment associated with untreated phenylketonuria. However, executive function impairments and psychiatric problems are frequently reported even for those treated early and continuously with the phenylalanine-restricted diet alone. Moreover, a large percentage of adults with phenylketonuria are reported as lost to follow-up by metabolic clinics. While a group of experts identified by the National Institutes of Health convenes to update treatment guidelines for phenylketonuria, we explore individual patient, social, and economic factors preventing >70% of adult phenylketonuria patients in the United States from accessing treatment. As more conditions are identified through newborn screening, factors affecting access to treatment grow in importance, and we must continue to be vigilant in assessing and addressing factors that affect patient treatment outcomes and not just celebrate amelioration of the most severe manifestations of disease.

Dispersion of PCB in the environment following an atmospheric release caused by a fire.

During a fire at a power plant located in the coastal plain of Israel, PCBs were released to the atmosphere from a ruptured transformer. Since PCBs are probably carcinogenic to humans, this study was performed in order to assess the environmental contamination by PCBs via the atmospheric pathway and the need for remediation measures. The release conditions and the meteorological conditions which prevailed during the fire were analyzed. This provided the input to a Gaussian dispersion model used to estimate the downwind-contaminated sector as well as the location of the maximal concentration within this sector. A sampling plan was then devised and vegetation collected within this sector was analyzed for PCBs. A methodology was developed to convert PCB concentrations in vegetation to concentrations in the atmosphere. It allowed a reconstitution of the PCB source term to the atmosphere from the vegetation measurements. The PCB concentrations were found to be lower than the USEPA decontamination standards. Remediation measures were not needed beyond the plant fence.

Sheltering : A protective measure following an accidental atmospheric release from a nuclear power plant

The effectiveness of sheltering the population for reducing radiological effects following an accidental release of radioactivity at a nuclear power plant was investigated. Different levels of respiratory protection and the administration of a thyroid blocking agent were also studied as possible complements to sheltering. Specific conditions were assumed, concerning the high protection factors of regular buildings and the high availability of civil defense shelters. Computations were performed by means of probabilistic consequence model, which allows a comprehensive description of exposure modes and processes dealing with the implementation of sheltering and which takes into account a broad range of radiological effects. Sheltering, even in regular buildings, as found to be efficient in reducing early fatalities and other non-stochastic effects. However, it was shown that respiratory protection is also needed in order to alleviate stochastic effects and that, for this purpose, expedient inividual filtration methods may be satisfactory. Under the conditions studied,sheltering was found to be preferable in most cases over evacuation, as the main inmediate protective measure, unless evacuation can be carried out before th radioactive cloud reaches the populated area