Surgical factors associated with new-onset postoperative atrial fibrillation after lung resection: the EPAFT multicentre study.

PURPOSE OF THE STUDY: Postoperative atrial fibrillation (POAF) is a recognised complication in approximately 10% of major lung resections. In order to best target preoperative treatment, this study aimed at determining the association of incidence of POAF in patients undergoing lung resection to surgical and anatomical factors, such as surgical approach, extent of resection and laterality. STUDY DESIGN: Evaluation of Post-operative Atrial Fibrillation in Thoracic surgery (EPAFT): a multicentre, population-based, retrospective, cross-sectional, observational study including 1367 patients undergoing lung resections between April 2016 and March 2017. The primary outcome was the presence of POAF following resection. POAF was defined as at least one episode of symptomatic or asymptomatic AF confirmed by ECG within 7 days from the thoracic procedure or prior to discharge from the hospital. RESULTS: POAF was observed in 7.4% of patients: 3.1% in minor resection (video-assisted thoracoscopic surgery (VATS): 2.5%; thoracotomy: 3.8%), 9.0% in simple lobectomy (VATS: 7.3%, thoracotomy: 9.9%), 6.0% in complex resection (thoracotomy: 6.3%) and 11.4% in pneumonectomy. POAF was higher in left (4.0%) vs right (2.4%) minor resections, and in left (9.9%) vs right (8.3%) lobectomy, but higher in right (7.5%) complex resections, and the highest in right pneumonectomy (17.6%). No significant variations were observed as per sex, laterality or resected lobes. A positive univariable and multivariable association was observed for increasing age and increasing extent of resection, but not thoracotomy. Median (Q1-Q3) hospital stay was 9 (7-14) days in POAF and 5 (4-7) days in non-AF patients (p<0.001), with an increased cerebrovascular accident burden (p<0.001) and long-term mortality (p<0.001). CONCLUSIONS: Among patients undergoing lung resection, POAF was significantly associated with age, increasing invasiveness of approach and increasing extent of resection. In addition, POAF carried a significant long-term mortality rate and burden of cerebrovascular accident. Appropriate prophylaxis should be targeted at these groups.

Digital Twins of the Water Cooling System in a Power Plant Based on Fuzzy Logic.

In the search for increased productivity and efficiency in the industrial sector, a new industrial revolution, called Industry 4.0, was promoted. In the electric sector, power plants seek to adapt these new concepts to optimize electric power generation processes, as well as to reduce operating costs and unscheduled downtime intervals. In these plants, PID control strategies are commonly used in water cooling systems, which use fans to perform the thermal exchange between water and the ambient air. However, as the nonlinearities of these systems affect the performance of the drivers, sometimes a greater number of fans than necessary are activated to ensure water temperature control which, consequently, increases energy expenditure. In this work, our objective is to develop digital twins for a water cooling system with auxiliary equipment, in terms of the decision making of the operator, to determine the correct number of fans. This model was developed based on the algorithm of automatic extraction of fuzzy rules, derived from the SCADA of a power plant located in the capital of Paraíba, Brazil. The digital twins can update the fuzzy rules in the case of new events, such as steady-state operation, starting and stopping ramps, and instability. The results from experimental tests using data from 11 h of plant operations demonstrate the robustness of the proposed digital twin model. Furthermore, in all scenarios, the average percentage error was less than 5% and the average absolute temperature error was below 3 °C.

Is the use of dual antiplatelet therapy following urgent and emergency coronary artery bypass surgery associated with increased risk of cardiac tamponade?

BACKGROUND AND AIM: Cardiac tamponade is a recognized post-cardiac surgery complication, resulting in increased morbidity and mortality. The 2016 American College of Cardiology and American Heart Association Guidelines recommended the use of Dual Antiplatelet Therapy (DAPT) in the management of patients undergoing urgent or emergency coronary artery bypass grafting (CABG). The effect of DAPT on cardiac tamponade rates was investigated in comparison to aspirin monotherapy (AMT). MATERIALS AND METHODS: Prospectively collected data from a tertiary cardiac surgery center was analyzed to identify the patients who underwent urgent and emergency CABG between January 2015 and January 2018. The patients were categorized as aspirin monotherapy (AMT) and Dual Antiplatelet Therapy (DAPT) groups. The primary outcome was total cardiac tamponade rate and secondary outcomes were length of hospitalization and 30-days and 1-year mortality. RESULTS: A total of 246 eligible patients were included across both arms and compared for confounding variables. Cardiac tamponade was observed in 9 (7.3%) and 8 (6.5%) of AMT and DAPT groups, respectively (P=0.802). The average hospital stay in days was similar in both groups (AMT=8.4 vs. DAPT=8.1, P=0.82), whereas tamponade patients experienced a significantly longer hospitalization when compared to non-tamponade patients (9.8 vs. 8.1 days, P=0.047). The 30-days and 1-year mortality were similar in both groups and were 0.8% and 1.6%, respectively. CONCLUSION: Overall, this study demonstrated that DAPT in urgent or emergency CABG patients is not associated with an increased risk of cardiac tamponade, length of hospital stay or mortality. RELEVANCE FOR PATIENTS: This study demonstrated that the use of DAPT in patients undergoing CABG as an urgent or emergency procedure following myocardial infarction is not associated with an increased risk of bleeding and has many associated benefits.

The impact of closed incision negative pressure therapy on prevention of median sternotomy infection for high risk cases: a single centre retrospective study.

BACKGROUND: Sternal wound infection (SWI) following cardiothoracic surgery is a major complication. It may significantly impact patient recovery, treatment cost and mortality rates. No universal guideline exists on SWI management, and more recently the focus has become prevention over treatment. Recent studies report positive outcomes with closed incision negative pressure therapy (ciNPT) on surgical incisions, particularly for patients at risk of poor wound healing. OBJECTIVE: This study aims to assess the effect of ciNPT on SWI incidence in high-risk patients. METHODS: A retrospective study was performed to investigate the benefit of ciNPT post sternotomy. Patients 3 years before the introduction of ciNPT (Control group) and 3 years after ciNPT availability (ciNPT group) were included. Only patients that had two or more of the risk factors; obesity, Chronic Obstructive Pulmonary Disease, old age and diabetes mellitus in the High Risk ciNPT cohort were given the ciNPT dressing. Patient demographics, EuroSCOREs and length of staywere reported as mean ± standard deviation. The Fisher's exact test (two-tailed) and an unpaired t-test (two-tailed) were used to calculate the p-value for categorical data and continuous data, respectively. RESULTS: The total number of patients was 1859 with 927 in the Control group and 932 in the ciNPT group. No statistical differences were noted between the groups apart from the Logistic EuroSCORE (Control = 6.802 ± 9.7 vs. ciNPT = 8.126 ± 11.3; P = 0.0002). The overall SWI incidence decreased from 8.7 to 4.4% in the overall groups with the introduction of ciNPT (P = 0.0005) demonstrating a 50% reduction. The patients with two and above risk factor in the Control Group (High Risk Control Group) were 162 while there was 158 in the ciNPT Group (High Risk ciNPT Group). The two groups were similar in all characteristics. Although the superficial and deep sternal would infections were higher in the High Risk Control Group versus the High Risk ciNPT group patients (20(12.4%) vs 9(5.6%); P = 0.049 respectively), the length of postoperative stay was similar in both (13.0 ± 15.1 versus 12.2 ± 15.6 days; p + 0.65). However the patients that developed infections in the two High Risk Groups stayed significantly longer than those who did not (25.5 ± 27.7 versus 12.2 ± 15.6 days;P = 0.008). There were 13 deaths in Hospital in the High Risk Control Group versus 10 in the High Risk ciNPT Group (P = 0.66). CONCLUSION: In this study, ciNPT reduced SWI incidence post sternotomy in patients at risk for developing SWI. This however did not translate into shorter hospital stay or mortality.

Do age-associated changes of voltage-gated sodium channel isoforms expressed in the mammalian heart predispose the elderly to atrial fibrillation?

Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide. The prevalence of the disease increases with age, strongly implying an age-related process underlying the pathology. At a time when people are living longer than ever before, an exponential increase in disease prevalence is predicted worldwide. Hence unraveling the underlying mechanics of the disease is paramount for the development of innovative treatment and prevention strategies. The role of voltage-gated sodium channels is fundamental in cardiac electrophysiology and may provide novel insights into the arrhythmogenesis of AF. Nav1.5 is the predominant cardiac isoform, responsible for the action potential upstroke. Recent studies have demonstrated that Nav1.8 (an isoform predominantly expressed within the peripheral nervous system) is responsible for cellular arrhythmogenesis through the enhancement of pro-arrhythmogenic currents. Animal studies have shown a decline in Nav1.5 leading to a diminished action potential upstroke during phase 0. Furthermore, the study of human tissue demonstrates an inverse expression of sodium channel isoforms; reduction of Nav1.5 and increase of Nav1.8 in both heart failure and ventricular hypertrophy. This strongly suggests that the expression of voltage-gated sodium channels play a crucial role in the development of arrhythmias in the diseased heart. Targeting aberrant sodium currents has led to novel therapeutic approaches in tackling AF and continues to be an area of emerging research. This review will explore how voltage-gated sodium channels may predispose the elderly heart to AF through the examination of laboratory and clinical based evidence.

Differential effects of atrial and brain natriuretic peptides on human pulmonary artery: An in vitro study.

BACKGROUND: The prevalence of cardiovascular diseases, especially heart failure, continues to rise worldwide. In heart failure, increasing levels of circulating atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) are associated with a worsening of heart failure and a poor prognosis. AIM: To test whether a high concentration of BNP would inhibit relaxation to ANP. METHODS: Pulmonary arteries were dissected from disease-free areas of lung resection, as well as pulmonary artery rings of internal diameter 2.5-3.5 mm and 2 mm long, were prepared. Pulmonary artery rings were mounted in a multiwire myograph, and a basal tension of 1.61gf was applied. After equilibration for 60 min, rings were pre-constricted with 11.21 µmol/L PGF2α (EC80), and concentration response curves were constructed to vasodilators by cumulative addition to the myograph chambers. RESULTS: Although both ANP and BNP were found to vasodilate the pulmonary vessels, ANP is more potent than BNP. pEC50 of ANP and BNP were 8.96 ± 0.21 and 7.54 ± 0.18, respectively, and the maximum efficacy (Emax) for ANP and BNP was -2.03 gf and -0.24 gf, respectively. After addition of BNP, the Emax of ANP reduced from -0.96gf to -0.675gf (P = 0.28). CONCLUSION: BNP could be acting as a partial agonist in small human pulmonary arteries, and inhibits relaxation to ANP. Elevated levels of circulating BNP could be responsible for the worsening of decompensated heart failure. This finding could also explain the disappointing results seen in clinical trials of ANP and BNP analogues for the treatment of heart failure.

Patient Experience in Health Center Medical Homes.

The Human Resource and Services Administration, Bureau of Primary Health Care Health Center program was developed to provide comprehensive, community-based quality primary care services, with an emphasis on meeting the needs of medically underserved populations. Health Centers have been leaders in adopting innovative approaches to improve quality care delivery, including the patient centered medical home (PCMH) model. Engaging patients through patient experience assessment is an important component of PCMH evaluation and a vital activity that can help drive patient-centered quality improvement initiatives. A total of 488 patients from five Health Center PCMHs in south Florida were surveyed in order to improve understanding of patient experience in Health Center PCMHs and to identify quality improvement opportunities. Overall patients reported very positive experience with patient-centeredness including being treated with courtesy and respect (85 % responded "always") and communication with their provider in a way that was easy to understand (87.7 % responded "always"). Opportunities for improvement included patient goal setting, referrals for patients with health conditions to workshops or educational programs, contact with the Health Center via phone and appointment availability. After adjusting for patient characteristics, results suggest that some patient experience components may be modified by educational attainment, years of care and race/ethnicity of patients. Findings are useful for informing quality improvement initiatives that, in conjunction with other patient engagement strategies, support Health Centers' ongoing transformation as PCMHs.

Privatization of solid waste collection services: Lessons from Gaborone.

Formal privatization of solid waste collection activities has often been flagged as a suitable intervention for some of the challenges of solid waste management experienced by developing countries. Proponents of outsourcing collection to the private sector argue that in contrast to the public sector, it is more effective and efficient in delivering services. This essay is a comparative case study of efficiency and effectiveness attributes between the public and the formal private sector, in relation to the collection of commercial waste in Gaborone. The paper is based on analysis of secondary data and key informant interviews. It was found that while, the private sector performed comparatively well in most of the chosen indicators of efficiency and effectiveness, the public sector also had areas where it had a competitive advantage. For instance, the private sector used the collection crew more efficiently, while the public sector was found to have a more reliable workforce. The study recommends that, while formal private sector participation in waste collection has some positive effects in terms of quality of service rendered, in most developing countries, it has to be enhanced by building sufficient capacity within the public sector on information about services contracted out and evaluation of performance criteria within the contracting process.

[Peritoneal and intestinal tuberculosis: an ancestral disease that poses new challenges in the technological era. Case report and review of the literature]. / Tuberculosis peritoneal e intestinal: una enfermedad ancestral que impone nuevos retos en la era tecnológica. informe de un caso y revisión de la literatura.

UNLABELLED: Tuberculosis is a public health problem. The most common presentation is pulmonary disease. The diagnosis of any extrapulmonary forms are quite difficult. Clinical manifestations of gastrointestinal tuberculosis are non-specific and compatible with pathologies such as inflammatory bowel disease, advanced ovarian cancer, deep mycosis, yersinia infection and amebomas. Abdominal form is located at 6th place of the extrapulmonary forms, after lymphatic, genitourinary, osteoarticular, miliary and meningeal infections. Eventually, 25 to 75% of patients with abdominal tuberculosis will require surgery. These procedures should be limitated with the purpose to preserve small bowel. Resection should be limitated for complicated cases. The surgical indications include: Intestinal occlusion (15-60%), perforation (1-15%), abscesses and fistulas (2-30%) and hemorrhage (2%). CONCLUSIONS: In most of the cases, the diagnosis of peritoneal or intestinal tuberculosis is made during a laparoscopy or laparotomy even during surgery performed by different purposes. Excessive manipulation of the intraabdominal organs may produced unexpected bowel lesions, increasing morbidity and mortality. Medical treatment is highly effective in the resolution of moderate complications such as bowel obstruction. Resectional procedures should be reserved for complications like perforation, bleeding or stenosis non-suitable for stricturoplasty.

[Bursting pressure in normal and ischemic colonic anastomoses in rats; using biological and synthetic adhesives]. / Presión de estallamiento en anastomosis de colon normal e isquémico en ratas, con adhesivos tisulares biológicos y sintéticos.

OBJECTIVE: We wanted to determine bursting pressure in normal and ischemic colonic anastomoses in rats as well as the frequency and type of complications with the use of biological and synthetic adhesives. MATERIAL AND METHODS: We designed an experimental study using 80 Sprague-Dawley rats, weighing between 200 and 250 g, divided into four groups: one control group and three study groups. Anastomoses were realized using one layer of interrupted 6-0 polypropylene sutures. Each group was divided into two categories: normal colon (n = 10) and ischemic colon, induced by dividing mesenteric blood vessels (n = 10). Group 2 used octyl-cyanoacrylate, group 3 used N-2-butyl-cyanoacrylate, and group 4 used 40 mg/ml fibrinogen with 1000 u/ml of thrombin. Bursting pressure was measured with a manometer creating pressure in the anastomotic bowel using an infusion pump at 1 ml/min of NaCl 0.9%. Statistical analysis was performed with Student's t test, one-way ANOVA, chi square test or Fisher's exact test. RESULTS: Group 1: (control) normal 127.8 +/- 16.21 versus 109 +/- 17 with ischemia (p < 0.05); group 2: normal 145.5 +/- 89 versus ischemic colon 97.6 +/- 40 (p = 0.136); group 3: normal 145.7 +/- 34 versus 130.8 +/- 15.33 with ischemia (p = 0.22); group 4: normal 239 +/- 26.4 versus 196.5 +/- 14.3 with ischemia (0.000). Bursting pressure was statistically significant in group 4, showing greater pressures (p < 0.001). Bursting segment was shown to be higher outside the anastomoses. Complications such as adhesions and intestinal obstruction were seen more frequently in both cyanoacrylate groups. CONCLUSIONS: An increased bursting pressure was shown in the fibrinogen groups, having a greater tensile strength of the anastomoses. Pressures similar when anastomoses were treated with any of the other two synthetic adhesives.

ITS region of the rDNA of Pythium rhizosaccharum sp. nov. isolated from sugarcane roots: taxonomy and comparison with related species.

Pythium rhizosaccharum (F-1244) was isolated from soil samples taken in the rhizosphere of sugarcane (Saccharum officinarum) in the north-eastern India. This species is characterized by its smooth-walled, spherical sporangia and rarely formed sexual structures. When formed, the antheridial branches wrap around the oogonia and soon disappear after fertilization. The internal transcribed spacer (ITS) region of its rDNA is comprised of 904 bases. The taxonomical description of this new species and its comparison with related species are given here, together with the nucleotide sequences of the ITS1 and ITS2, and the 5.8S gene of its ribosomal nuclear DNA.