Significance of isolated postoperative atrial fibrillation in thoracic aortic aneurysm repair.

OBJECTIVE: Although postoperative atrial fibrillation has been shown to be associated with worse survival after thoracic aortic surgery, its effect on outcomes independently from other postoperative complications is not well understood. METHODS: This is a single-center retrospective study of patients who underwent open thoracic aortic aneurysm repair between March 2005 and March 2021. Postoperative atrial fibrillation was defined as new-onset atrial fibrillation that developed during the index hospital stay. Patients with preoperative atrial fibrillation were excluded. Postoperative major complications included reoperation for bleeding, respiratory failure, acute renal failure, and stroke. Variables associated with postoperative atrial fibrillation were analyzed with multivariable regression. Survival of patients without major complications was compared between patients without atrial fibrillation and patients with postoperative atrial fibrillation after propensity score matching for baseline and intraoperative characteristics. RESULTS: Of 1454 patients, 520 (35.8%) were observed to have postoperative atrial fibrillation. Patients with postoperative atrial fibrillation had a higher rate of postoperative major complications than those without atrial fibrillation (20.2% vs 12.2%, P < .001). Ten-year survival was 82.0% in patients with postoperative atrial fibrillation and 87.0% in patients without atrial fibrillation (P = .008). In the cohort of patients without complications, 10-year survival was similar between patients with and without postoperative atrial fibrillation after propensity score matching (83.6% vs 83.8%, P = .75). CONCLUSIONS: Postoperative atrial fibrillation is common after open proximal thoracic aortic aneurysm repair. Although development of major postoperative complications is associated with postoperative atrial fibrillation and decreased long-term survival, isolated postoperative atrial fibrillation does not appear to influence long-term survival.

Determinants in Tailoring Antidiabetic Therapies: A Personalized Approach.

Diabetes has become a pandemic as the number of diabetic people continues to rise globally. Being a heterogeneous disease, it has different manifestations and associated complications in different individuals like diabetic nephropathy, neuropathy, retinopathy, and others. With the advent of science and technology, this era desperately requires increasing the pace of embracing precision medicine and tailoring of drug treatment based on the genetic composition of individuals. It has been previously established that response to antidiabetic drugs, like biguanides, sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide 1 (GLP-1) agonists, and others, depending on variations in their transporter genes, metabolizing genes, genes involved in their action, etc . Responsiveness of these drugs also relies on epigenetic factors, including histone modifications, miRNAs, and DNA methylation, as well as environmental factors and the lifestyle of an individual. For precision medicine to make its way into clinical procedures and come into execution, all these factors must be reckoned with. This review provides an insight into several factors oscillating around the idea of precision medicine in type-2 diabetes mellitus.

Diabetes workshops for providers improve glucose control in coronary artery bypass grafting patients.

OBJECTIVES: Postoperative hyperglycemia occurs in up to 80% of cardiac surgery patients and is associated with poor outcomes. We sought to determine if case-based diabetes workshops for providers would improve postoperative glycemic control and outcomes in patients undergoing coronary artery bypass grafting  (CABG). METHODS: Healthcare providers taking care of patients in the cardiothoracic step-down unit underwent 30-min weekly case-based diabetes workshops over 6 months. Workshops focused on initiation of insulin treatment, titration of insulin dosing, and transitioning from insulin drips to subcutaneous insulin. Isolated-CABG patients were recorded during 29-month periods before (Jan 2013-June 2015) and after training (Jan 2016-June 2018). Glycemic control and outcomes were compared between groups balanced for preoperative risk factors using inverse probability treatment weights. RESULTS: A total of 938 and 1032 patients were included in pre- and posttraining groups, respectively. Compared to the pretraining period, the posttraining period had a lower median of mean patient day glucose levels (151 vs. 144 mg/dl, p < .001) and percentage of patient days with a glucose level >250 mg/dl (20% vs. 14%, p < .001). The percentage of patient days with mean glucose values in the target range (80-180 mg/dl) increased from 71% to 77% (p < .001). The incidence of hypoglycemic events did not significantly change after training (p = .15). The incidence of sepsis was significantly lower in the posttraining period (1.7% vs. 0.2%, p < .001). CONCLUSIONS: Weekly diabetes workshops for healthcare providers were associated with improved glycemic control and reduced postoperative sepsis among isolated CABG patients.

Association of GSTM1 and GSTT1 gene polymorphisms with COVID-19 susceptibility and its outcome.

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has become a global health issue and develops into a broad range of illnesses from asymptomatic to fatal respiratory diseases. SARS-CoV-2 infection is associated with oxidative stress that triggers cytokine production, inflammation, and other pathophysiological processes. Glutathione-S-transferase (GST) is an important enzyme that catalyzes the conjugation of glutathione (GSH) with electrophiles to protect the cell from oxidative damage and participates in the antioxidant defense mechanism in the lungs. Thus, in this study, we investigated the role of GSTM1 and GSTT1 gene polymorphism with COVID-19 susceptibility, as well as its outcome. The study included 269 RT-PCR confirmed COVID-19 patients with mild (n = 149) and severe (n = 120) conditions. All subjects were genotyped for GSTM1 and GSTT1 by multiplex polymerase chain reaction (mPCR) followed by statistical analysis. The frequency of GSTM1-/- , GSTT1-/- and GSTM1-/- /GSTT1-/- was higher in severe COVID-19 patients as compared to mild patients but we did not observe a significant association. In the Cox hazard model, death was significantly 2.28-fold higher in patients with the GSTT1-/- genotype (p = 0.047). In combination, patients having GSTM1+/+ and GSTT1-/- genotypes showed a poor survival rate (p = 0.02). Our results suggested that COVID-19 patients with the GSTT1-/- genotype showed higher mortality.

Patient Experiences Using an Inpatient Personal Health Record.

OBJECTIVE: To investigate patients' experience using an inpatient personal health record (PHR) on a tablet computer to increase engagement in their hospital care. METHODS: We performed observations and conducted semi-structured interviews with 14 post-operative cardiac surgical patients and their family members who received an inpatient PHR. Themes were identified using an inductive coding scheme. RESULTS: All participants responded favorably to having access to view their clinical information. A majority (85.7%) of participants used the application following an initial training session. Patients reported high satisfaction with being able to view their hospital medications and access educational materials related to their medical conditions. Patients reported a desire to view daily progress reports about their hospital stay and have access to educational information about their post-acute recovery. In addition, patients expressed a common desire to view their diagnoses, laboratory test results, radiology reports, and procedure notes in language that is patient-friendly. CONCLUSION: Patients have unmet information needs in the hospital setting. Our findings suggest that for some inpatients and their family members, providing personalized health information through a tablet computer may improve satisfaction, decrease anxiety, increase understanding of their health conditions, and improve safety and quality of care.

Association of Angiotensin-Converting Enzyme and Glutathione S-Transferase Gene Polymorphisms with Body Mass Index among Hypertensive North Indians.

OBJECTIVES: This study aimed to examine the association of angiotensin-converting enzyme (ACE) and glutathione S-transferase (GST) gene polymorphisms with body mass index (BMI) in hypertensive North Indians. METHODS: This case-control study was carried out between May 2013 and November 2014 at the Era's Lucknow Medical College & Hospital, Lucknow, India, and included 378 subjects divided into three groups. One group constituted 253 hypertensive individuals (sustained diastolic blood pressure of >90 mmHg and systolic blood pressure of >140 mmHg) who were subcategorised according to normal (<25 kg/m(2)) or high (≥25 kg/m(2)) BMI. The third group consisted of 125 age-, gender- and ethnically-matched normotensive controls with a normal BMI. Gene polymorphisms were evaluated by polymerase chain reaction. The genotypic and allelic frequency distribution among both groups were analysed. RESULTS: A significant difference was found between GST theta 1-null and GST mu 1-positive genotype frequencies among the hypertensive overweight/obese individuals and controls (P = 0.014 and 0.033, respectively). However, no difference was observed in the frequency of ACE polymorphisms. ACE insertion/insertion genotype (P = 0.006), insertion and deletion alleles (P = 0.007 each) and GST theta 1-null and GST theta 1-positive genotypes (P = 0.006 each) were found to differ significantly between hypertensive cases and controls, regardless of BMI. CONCLUSION: ACE and GST gene polymorphisms were not associated with BMI but were significantly associated with hypertension among the studied group of North Indians.

The role of vitamin e in human health and some diseases.

Vitamin E is the major lipid-soluble component in the cell antioxidant defence system and is exclusively obtained from the diet. It has numerous important roles within the body because of its antioxidant activity. Oxidation has been linked to numerous possible conditions and diseases, including cancer, ageing, arthritis and cataracts; vitamin E has been shown to be effective against these. Platelet hyperaggregation, which can lead to atherosclerosis, may also be prevented by vitamin E; additionally, it also helps to reduce the production of prostaglandins such as thromboxane, which cause platelet clumping. The current literature review discusses the functions and roles of vitamin E in human health and some diseases as well as the consequences of vitamin E deficiency. The main focus of the review is on the tocopherol class of the vitamers.

A Circular Surgical Stapler Designed to Anastomose Aorta and Dacron Tube Graft: Validation of the Concept and Comparison to Hand-Sewn Anastomosis in Bench Experiments.

BACKGROUND: A circular aortic stapler has been developed to anastomose the open end of the aorta to a size-matched Dacron tube graft in one quick motion and without having to pull sutures through the aortic wall. METHODS: A prototype was developed, and its design and function were tested in bench experiments and compared with hand-sewn anastomosis. The basic design of the stapler is a central rod (anvil) surrounded by 10 stapling limbs, which can be closed over the anvil in a full circle, with staples extruded by turning a knob at the back. To test its function, a Dacron tube graft was inserted in the middle of a length of bovine aorta. One side was anastomosed with the stapler and the other hand-sewn in each of 10 experiments. Bovine blood was infused under increasing pressure. RESULTS: It took considerably less time to complete the stapled anastomosis than the hand-sewn side (3 minutes, 46 seconds versus 15 minutes, 42 seconds). Initial leak occurred at low pressures on the hand-sewn side (mean pressure 40 mm Hg) compared with the stapled side (mean pressure 70 mm Hg). In 7 of 10 experiments, the leak became too brisk on the hand-sewn side to sustain pressure, compared with 3 of 10 with stapled anastomoses. The stapling device performed well in all cases except when the bovine aorta was too thick for the staples (two cases) or when there was a missed branch at the anastomotic site (one case). CONCLUSIONS: These experiments validate the concept and the design of this aortic stapler. There are some limitations in the current design, which will need to be modified before its use in live animals or clinically.

Left ventricular outflow tract obstruction provoked during dobutamine stress echocardiography predicts future chest pain, syncope, and near syncope.

BACKGROUND: Although dobutamine stress echocardiography (DSE) is associated with dynamic left ventricular (LV) obstruction, it is unknown whether such obstructive event, in general, and the specific site of obstruction, in particular, have unique clinical prognostic significance. We sought to determine whether dynamic LV outflow tract (LVOT) versus LV midcavitary obstruction provoked during DSE would predict future chest pain, syncope, and/or near syncope. METHODS: Two hundred thirty-seven patients (145 men and 92 women, mean age 58 +/- 13 [+/-SD] years) without DSE-provoked ischemia underwent continuous wave Doppler interrogation to detect any inducible dynamic flow obstruction. Patients were prospectively followed for a mean duration of 31 +/- 13 months. RESULTS: One hundred fifty-four of 237 patients had no provoked LV obstruction (group 1). Fifty-four (22.8%) had provoked LV midcavitary (group 2) obstruction, and 29 (12.2%) had outflow tract (group 3) obstruction. During follow-up, chest pain occurred more frequently in groups 2 (46%, P < .05) and 3 (52%, P = .05) as compared with group 1 (31%). A higher incidence of syncope and/or near syncope was noted in group 3 (21% vs 9% in group 1). LVOT obstruction but not midcavitary obstruction was a significant predictor of future chest pain (relative risk 2.63, P = .0021) and syncope and/or near syncope (relative risk 3.11, P = .036). Kaplan-Meier analysis showed a significantly less event-free survival (P = .025) for the combined end point of chest pain, syncope, and/or near syncope in patients with LVOT obstruction. CONCLUSIONS: This is the first prospective study to identify the differential prognostic implications of the site of dynamic obstruction noted during DSE. Our results demonstrate that DSE-provoked LVOT obstruction is an independent positive predictor of future episodes of chest pain and syncope and/or near syncope. These findings warrant larger studies addressing treatment options to ameliorate symptoms in this subgroup of patients.

Interval results with right gastroepiploic bypass.

OBJECTIVE: Right gastroepiploic artery bypass grafting has proved to be a viable surgical choice since the mid-1980s. Long-term graft patency, however, has been challenged ever since. We present 43 patients who underwent right gastroepiploic artery bypass surgery off pump with minimal invasive techniques with an average follow-up period of 57.9 months since 1996. METHODS: Operative methods are described and were confined to a subxiphoid incision. The series consists of 43 patients (38 male and 5 female) with an age range of 44 to 79 years. All patients had heart disease classified as Canadian Cardiovascular Society class III-IV and 35/43 (81.3%) of patients had undergone 1 to 3 reoperations. Postoperatively, 93% had no complications. Crude mortality was 2.3%, with an expected mortality of 4% and risk-adjusted mortality of 1.45%. Nine patients underwent combined procedures. RESULTS: Of the 43 patients, 41 were alive at 57.4 months (range, 20-76 months). Results of Doppler studies and angiography proved 95.3% and 91.6% patency. CONCLUSION: In this series, our highest-risk patients with reoperative coronary artery disease had low mortality and no intervention in this interval follow-up.