The effects of computerised cognitive training on post-CABG delirium and cognitive change: A prospective randomised controlled trial.

Background: Cognitive impairments, including delirium, are common after coronary artery bypass grafting (CABG). Improving cognition pre- and post-operatively using computerised cognitive training (CCT) may be an effective approach to improve cognitive outcomes in CABG patients. Objectives: Investigate the effect of remotely supervised CCT on cognitive outcomes, including delirium, in older adults undergoing CABG surgery. Methods: Thirty-six participants, were analysed in a single-blinded randomised controlled trial (CCT Intervention: n = 18, Control: n = 18). CCT was completed by the intervention group pre-operatively (every other day, 45-60-minute sessions until surgery) and post-operatively, beginning 1-month post-CABG (3 x 45-60-minute sessions/week for 12-weeks), while the control group maintained usual care plus weekly phone calls. Cognitive assessments were conducted pre- and post-operatively at multiple follow-ups (discharge, 4-months and 6-months). Post-operative delirium incidence was assessed daily until discharge. Cognitive change data were calculated at each follow-up for each cognitive test (Addenbrooke's Cognitive Examination III and CANTAB; z-scored). Results: Adherence to the CCT intervention (completion of three pre-operative or 66% of post-operative sessions) was achieved in 68% of pre-CABG and 59% of post-CABG participants. There were no statistically significant effects of CCT on any cognitive outcome, including delirium incidence. Conclusion: Adherence to the CCT program was comparatively higher than previous feasibility studies, possibly due to the level of supervision and support provided (blend of face-to-face and home-based training, with support phone calls). Implementing CCT interventions both pre- and post-operatively is feasible in those undergoing CABG. No statistically significant benefits from the CCT interventions were identified for delirium or cognitive function post-CABG, likely due to the sample size available (study recruitment greatly impacted by COVID-19). It also may be the case that multimodal intervention would be more effective.

Cardiac surgery on patients with COVID-19: a systematic review and meta-analysis.

INTRODUCTION: The COVID-19 pandemic has had a significant impact on global surgery. In particular, deleterious effects of SARS-CoV-2 infection on the heart and cardiovascular system have been described. To inform surgical patients, we performed a systematic review and meta-analysis aiming to characterize outcomes of COVID-19 positive patients undergoing cardiac surgery. METHODS: The study protocol was registered with PROSPERO (CRD42021228533) and conformed with PRISMA 2020 and MOOSE guidelines. PubMed, Ovid MEDLINE and Web of Science were searched between 1 January 2019 to 24 February 2022 for studies reporting outcomes on COVID-19 positive patients undergoing cardiac surgery. Study screening, data extraction and risk of bias assessment were conducted in duplicate. Meta-analysis was conducted using a random-effects model where at least two studies had sufficient data for that variable. RESULTS: Searches identified 4223 articles of which 18 studies were included with a total 44 patients undergoing cardiac surgery. Within these studies, 12 (66.7%) reported populations undergoing coronary artery bypass graft (CABG) surgery, three (16.7%) aortic valve replacements (AVR) and three (16.7%) aortic dissection repairs. Overall mean postoperative length of ICU stay was 3.39 (95% confidence interval (CI): 0.38, 6.39) and mean postoperative length of hospital stay was 17.88 (95% CI: 14.57, 21.19). CONCLUSION: This systematic review and meta-analysis investigated studies of limited quality which characterized cardiac surgery in COVID-19 positive patients and demonstrates that these patients have poor outcomes. Further issues to be explored are effects of COVID-19 on decision-making in cardiac surgery, and effects of COVID-19 on the cardiovascular system at a cellular level.

Computerised cognitive training to improve cognition including delirium following coronary artery bypass grafting surgery: protocol for a blinded randomised controlled trial.

INTRODUCTION: Coronary artery bypass grafting (CABG) surgery is known to improve vascular function and cardiac-related mortality rates; however, it is associated with high rates of postoperative cognitive decline and delirium. Previous attempts to prevent post-CABG cognitive decline using pharmacological and surgical approaches have been largely unsuccessful. Cognitive prehabilitation and rehabilitation are a viable yet untested option for CABG patients. We aim to investigate the effects of preoperative cognitive training on delirium incidence, and preoperative and postoperative cognitive training on cognitive decline at 4 months post-CABG. METHODS AND ANALYSIS: This study is a randomised, single-blinded, controlled trial investigating the use of computerised cognitive training (CCT) both pre-CABG and post-CABG (intervention group) compared with usual care (control group) in older adults undergoing CABG in Adelaide, South Australia. Those in the intervention group will complete 1-2 weeks of CCT preoperatively (45-60 min sessions, 3.5 sessions/week) and 12 weeks of CCT postoperatively (commencing 1 month following surgery, 45-60 min sessions, 3 sessions/week). All participants will undergo cognitive testing preoperatively, over their hospital stay including delirium, and postoperatively for up to 1 year. The primary delirium outcome variable will be delirium incidence (presence vs absence); the primary cognitive decline variable will be at 4 months (significant decline vs no significant decline/improvement from baseline). Logistic regression modelling will be used, with age and gender as covariates. Secondary outcomes include cognitive decline from baseline to discharge, and at 6 months and 1 year post-CABG. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Central Adelaide Local Health Network Human Research Ethics Committee (South Australia, Australia) and the University of South Australia Human Ethics Committee, with original approval obtained on 13 December 2017. It is anticipated that approximately two to four publications and multiple conference presentations (national and international) will result from this research. TRIAL REGISTRATION NUMBER: This clinical trial is registered with the Australian New Zealand Clinical Trials Registry and relates to the pre-results stage. Registration number: ACTRN12618000799257.

Mortality in Australian Cardiothoracic Surgery: Findings From a National Audit.

BACKGROUND: Independent peer review of mortality cases has potential to identify issues in cardiothoracic surgical patients. The Australian and New Zealand Audit of Surgical Mortality aims to improve surgical care through peer-reviewed assessment of all surgical mortality. The aim of this study was to describe common clinical management issues that contribute to patient mortality in a cohort of Australian cardiothoracic surgical patients. This approach may subsequently provide a basis for quality improvement. METHODS: Cardiothoracic mortality reports to the Australian and New Zealand Audit of Surgical Mortality from February 2009 through December 2015 were reviewed. The surgeon report and assessor comments were coded to identify clinical management issues. These were divided into perioperative stages (preoperative, intraoperative, and postoperative), and at each stage a thematic analysis was performed. RESULTS: Of the 908 cases analyzed, 1371 clinical management issues were identified. Postoperative issues were the most common (n = 552), followed by preoperative (n = 378) and intraoperative issues (n = 370). Communication issues were present at all 3 stages (n = 71). Overall the most common theme was intraoperative technical issues (n = 287). Many of these issues revolved around unintentional injury to anatomic structures during surgery and inadequate myocardial protection. Communication issues commonly related to surgical handover to the intensive care unit and lack of shared decision-making. Also common were consultant surgeons being unaware of patient deterioration or significant changes in management. CONCLUSIONS: The Australian and New Zealand Audit of Surgical Mortality provides valuable insights into issues affecting mortality in cardiothoracic patients. Potentially avoidable management issues play a large role in determining the outcome of these patients. Quality improvement initiatives targeting these areas may be valuable.

"Nobody told me": Communication Issues Affecting Australian Cardiothoracic Surgery Patients.

BACKGROUND: Failure of communication can have potentially severe results in cardiothoracic surgery. Previous literature regarding patient safety highlighted communication as a common area for improvement. This study utilized a qualitative approach to analyze a national mortality audit data set to identify and describe communication issues that could potentially contribute to patient mortality following cardiothoracic surgery. METHODS: We utilized a peer-reviewed audit of surgical deaths after cardiothoracic surgery in Australian hospitals from 2009 to 2015 via the Australian and New Zealand Audit of Surgical Mortality. Cases were identified with clinical management issues then individual analysis of cases highlighting communication issues was undertaken. A total of 91 reports from surgeons and assessors were analysed using a thematic analytic approach. RESULTS: A total of 908 cases of potentially avoidable mortality were identified as being associated with clinical management issues, and communication issues were identified in 91 (10%) of these cases, which served as the basis for this analysis. The study found that failure to achieve shared decision making was the most common theme (n = 38, 41.8%), followed by failure to notify patient deterioration (n = 22, 24.1%), misreporting of patient condition (n = 10, 11.0%) and issues related to informed consent (n = 9, 10.0%). The most frequent communication issues occurred between surgeons and the intensive care unit. CONCLUSIONS: Poor communication was identified in patients who died after cardiothoracic surgery. Communication is an important modifiable factor in patient mortality. Efforts to address teamwork and communication have the potential to improve safety and quality of care for patients undergoing cardiothoracic surgery.

Novel Sternal Reconstruction With Custom Three-Dimensional-Printed Titanium PoreStar Prosthesis.

Resection of sternal tumors can leave large defects, which exposes major mediastinal structures, and can affect respiratory mechanics. If feasible, resection is potentially a complex reconstructive challenge to restore normal and functional anatomy using conventional techniques. We report the first Australian use of a three-dimensional-printed titanium and PoreStar prosthesis in a 39-year-old woman for reconstruction after major surgical resection of the sternum for metastatic breast cancer. The patient successfully underwent excision of the sternum and costal cartilages as well as implantation of the prosthesis. We conclude that three-dimensional-printed prostheses are technically feasible to deliver excellent cosmetic result.

Prevention of Sternal Wound Infections by use of a Surgical Incision Management System: First Reported Australian Case Series.

BACKGROUND: Sternal wound infections are considered a costly and potentially devastating consequence of the median sternotomy in cardiothoracic surgery. Surgical incision management employs the technique of applying a closed, negative pressure vacuum dressing to a closed wound. Several studies have demonstrated a reduction in sternal wound infections using this system. METHODS: A retrospective audit of cases receiving surgical incision management demonstrated a statistically significant reduction in sternal wound infections against a predicted rate. RESULTS: Of the 62 patients identified, only one was complicated by a sternal wound infection with the greatest reduction seen in the high-risk infection group. CONCLUSIONS: Although smaller in size, the results compared well to trials conducted in larger European and US centres. Although not advocating surgical incision management for routine use, it should be considered on patients considered high-risk for sternal wound infection, such as diabetics, the elderly and the obese.

Posttraumatic stress disorder after occupational HIV exposure: two cases and a literature review.

Two healthcare workers developed disabling chronic posttraumatic stress disorder after needlestick exposures to blood from a patient infected with human immunodeficiency virus (HIV), even though both continue to test negative for HIV antibody more than 22 months after their exposures. We describe these 2 cases and review the relevant literature. Prospective studies of psychological morbidity after occupational needlestick injuries are required to determine the role of long-term psychological follow-up, counseling, and support.

Infections associated with use of the LifeSite Hemodialysis Access System.

We observed infection rates associated with the LifeSite Hemodialysis Access System, a novel dialysis device consisting of 2 subcutaneously implanted valves accessed by repeated use of fibrous tissue tracts, of 4.8 total infections and 8.1 first episodes per 1000 patient-days. These rates are higher than those observed elsewhere, which may be related to use of the device in a population of chronically ill patients, to the learning curve associated with use of the device, or to inherent qualities of the device.