Nurses as Warriors: Challenges and Impacts among Kerala Nurses during Coronavirus Disease-2019 Pandemic.

Introduction: In December 2019, the global outbreak of coronavirus disease-2019 (COVID-19) was announced. The pandemic has cast a spotlight like never before on health-care professionals in general, and nurses in particular. Nurses have been dubbed "warriors" by the general public for their determination to provide frontline care to patients with the disease, despite the risk of exposure and a lack of professional resources. The goal of the study was to assess the obstacles and consequences faced by Kerala nurses during the COVID-19 pandemic. Materials and Methods: A cross-sectional study was conducted from January to June 2021 among Kerala nurses. A total of 1630 nurses were chosen using a randomized sampling technique. The data were gathered using a semi-structured self-reported questionnaire. The information was entered into a database and analyzed using SPSS program version 16.0. Results: After analyzing the data, seven themes emerged: (a) love for the profession; (b) frustration for being labeled as "COVID Nurses"; (c) fear of infection and transmission; (d) personal protective equipment uncertainty; (e) workplace safety especially against hospital violence; (f) burnout in nurses; and (g) job stress. Conclusion: Nurses undertook a hazardous rescue mission and played an essential contribution in COVID-19 pandemic. Over the course of intensive work, they underwent significant psychological changes. Nurses burnout and occupational stress must be addressed with effective interventions. In order to mitigate the pandemic, the administration should also promote a healthy workplace and have a positive attitude and harmonious connection with the frontline personnel.

Activation of the stress response among the cardiac surgical residents: comparison of teaching procedures and other (daily) medical activities.

BACKGROUND: The aim of this Pilot study was to investigate the cardiac surgical residents' workload during different surgical teaching interventions and to compare their stress levels with other working time spent in the intensive care unit or normal ward. METHODS: The objective stress was assessed using two cardiac surgical residents' heart rate variability (HRV) both during surgical activities (32 selected teaching operations (coronary artery bypass graft n = 26 and transcatheter aortic valve implantation n = 6), and during non-surgical periods. Heart rate, time and frequency domains as well as non-linear parameters were analyzed using the Wilcoxon test. RESULTS: The parasympathetic activity was significantly reduced during the surgical phase, compared to the non-surgical phase: Mean RR (675.7 ms vs. 777.3 ms), RMSSD (23.1 ms vs. 34.0 ms) and pNN50 (4.7% vs. 10.6%). This indicates that the residents had a higher stress level during surgical activities in comparison to the non-surgical times. The evaluation of the Stress Index during the operations and outside the operating room (8.07 vs. 10.6) and the parasympathetic nervous system index (- 1.75 to - 0.91) as well as the sympathetic nervous system index (1.84 vs. 0.65) confirm the higher stress level during surgery. This can be seen too used the FFT Analysis with higher intraoperative LF/HF ratio (6.7 vs. 3.8). CONCLUSION: HRV proved to be a good, objective method of identifying stress among physicians both in and outside the operating room. Our results show that residents are exposed to high psychological workloads during surgical activities, especially as the operating surgeon.

Surgery for infective endocarditis following low-intermediate risk transcatheter aortic valve replacement-a multicentre experience.

OBJECTIVES: With the expansion of transcatheter aortic valve replacement (TAVR) into intermediate and low risk, the number of TAVR procedures is bound to rise and along with it the number of cases of infective endocarditis following TAVR (TIE). The aim of this study was to review a multicentre experience of patients undergoing surgical intervention for TIE and to analyse the underlying indications and operative results. METHODS: We retrospectively identified and analysed 69 patients who underwent cardiac surgery due to TIE at 9 cardiac surgical departments across Germany. The primary outcome was operative mortality, 6-month and 1-year survival. RESULTS: Median age was 78 years (72-81) and 48(69.6%) were male. The median time to surgical aortic valve replacement was 14 months (5-24) after TAVR, with 32 patients (46.4%) being diagnosed with early TIE. Cardiac reoperations were performed in 17% of patients and 33% underwent concomitant mitral valve surgery. The main causative organisms were: Enterococcus faecalis (31.9%), coagulase-negative Staphylococcus spp. (26.1%), Methicillin-sensitive Staphylococcus aureus (15.9%) and viridians group streptococci (14.5%). Extracorporeal life support was required in 2 patients (2.9%) for a median duration of 3 days. Postoperative adverse cerebrovascular events were observed in 13 patients (18.9%). Postoperatively, 9 patients (13.0%) required a pacemaker and 33 patients (47.8%) needed temporary renal replacement therapy. Survival to discharge was 88.4% and survival at 6 months and 1 year was found to be 68% and 53%, respectively. CONCLUSIONS: Our results suggest that TIE can be treated according to the guidelines for prosthetic valve endocarditis, namely with early surgery. Surgery for TIE is associated with acceptable morbidity and mortality rates. Surgery should be discussed liberally as a treatment option in patients with TIE by the 'endocarditis team' in referral centres.

Monitoring excimer laser-guided cardiac lead extractions by uniportal video-assisted thoracoscopy: A single center experience.

BACKGROUND: Though laser guided extractions of cardiac implantable electronic devices leads have become a routine procedure, the severe complications are associated with a high mortality. Here, we report our single center experience using uniportal video-assisted thoracoscopy for laser lead extraction and compare it to stand-alone laser lead extraction. METHODS: The intraoperative data and postoperative clinical outcomes of patients undergoing laser lead extraction with concomitant thoracoscopy (N = 28) or without (N = 43) in our institution were analyzed retrospectively. RESULTS: Neither the median x-ray time (612.0 s for the thoracoscopy group vs. 495.5 s for the non-thoracoscopy group, p = 0.962), length of the operation (112.5 vs. 100.0 min, p = 0.676) or the median length of hospital stay (9.0 vs. 10.0 days, p = 0.990) differed significantly. The mean intensive care unit stay was longer for patients in the non-thoracoscopy group (0.8 vs. 2.5 days, p = 0.005). The 30-day-mortality in the thoracoscopy group was zero, whereas five patients died in the non-thoracoscopy group. Furthermore, four patients in the non-thoracoscopy group had encountered haemothorax, while none were observed in the thoracoscopy group (p = 0.148). CONCLUSIONS: The adoption of uniportal video-assisted thoracoscopy during laser-guided lead extraction of cardiac implantable electronic devices can be considered safe and does not lengthen the operating time or hospital stay. It might be useful in the detection of severe complications and, in experienced hands, possibly allow direct bleeding control.

Comparative Evaluation on Impacts of Fibronectin, Heparin-Chitosan, and Albumin Coating of Bacterial Nanocellulose Small-Diameter Vascular Grafts on Endothelialization In Vitro.

In this study, we contrast the impacts of surface coating bacterial nanocellulose small-diameter vascular grafts (BNC-SDVGs) with human albumin, fibronectin, or heparin-chitosan upon endothelialization with human saphenous vein endothelial cells (VEC) or endothelial progenitor cells (EPC) in vitro. In one scenario, coated grafts were cut into 2D circular patches for static colonization of a defined inner surface area; in another scenario, they were mounted on a customized bioreactor and subsequently perfused for cell seeding. We evaluated the colonization by emerging metabolic activity and the preservation of endothelial functionality by water soluble tetrazolium salts (WST-1), acetylated low-density lipoprotein (AcLDL) uptake assays, and immune fluorescence staining. Uncoated BNC scaffolds served as controls. The fibronectin coating significantly promoted adhesion and growth of VECs and EPCs, while albumin only promoted adhesion of VECs, but here, the cells were functionally impaired as indicated by missing AcLDL uptake. The heparin-chitosan coating led to significantly improved adhesion of EPCs, but not VECs. In summary, both fibronectin and heparin-chitosan coatings could beneficially impact the endothelialization of BNC-SDVGs and might therefore represent promising approaches to help improve the longevity and reduce the thrombogenicity of BNC-SDVGs in the future.

Novel Surgical Technique to Prevent Left Ventricular Rupture After Mitral Valve Replacement.

Left ventricular rupture, also called atrioventricular disruption, remains a rare but lethal complication of mitral valve replacement. Available measures for preventing such a complication are limited to preservation of the posterior mitral leaflet and avoidance of overzealous decalcification of the annulus. Moreover, these strategies are not always feasible when annular calcifications prevent proper suture placement or when an abscess involves the mitral annulus. This report describes a surgical technique practiced in our clinic (Department of Cardiothoracic Surgery, University Hospital, Otto-von-Guericke-University, Magdeburg, Germany) that can be used in such high-risk patients to avoid left ventricular rupture.

Case series of late complications after transcatheter mitral annuloplasty using Cardioband and surgical treatment options.

BACKGROUND: Treatment of functional mitral regurgitation using transcatheter techniques such as the Cardioband annuloplasty device (Edwards Lifesciences) has gained wide acceptance in the recent years. However, complications of such devices are rarely reported. METHODS: Here, we present a case series involving two patients with dislocation of the Cardioband device and discuss the surgical management. RESULTS: In the former the valve was re-repaired by surgical implantation of an annuloplasty ring, and in the latter the valve had to be replaced due to severe damage of the mitral valve annulus. Both patients had an uncomplicated course and were discharged to rehabilitation Center. CONCLUSION: Dislocation of the Cardioband devices can be successfully managed by surgical approaches. Depending on the extent of damage to the mitral valve annulus, the valve could be re-repaired or should be repalced.

Temperature effect on biochar produced from tea (Camellia sinensis L.) pruning litters: A comprehensive treatise on physico-chemical and statistical approaches.

The present study aimed to optimize the production of biochar from tea (Camellia sinensis L.) pruning litter. Characterization of biochar prepared from four tea pruning litters (mixed, Tocklai Vegetative 1, 22 and 25) at five pyrolysis temperatures (250, 300, 350, 400, 450, and 500 °C for 3 h) were documented. The results demonstrated that yield, total nitrogen, H:C, and O:C decreased steadily with increasing pyrolysis temperature. However, water holding capacity, ash content, fixed carbon, C:N, NH4+-N, NO3--N, trace elements, total P and K, and germination index increased consistently with increasing pyrolysis temperature. All the prepared biochars are suitable for agriculture application as H:C and O:C ratios of prepared biochars are <0.6 and <0.4, respectively. Low pyrolysis temperature (<300 °C) was optimal to get more stable biochar with respect to essential nutrients. Biochar derived from Tocklai Vegetative 1 at 300 °C has more potential for agronomic applications. Principal component analysis showed >96% variability.

An In Vitro Hemodynamic Loop Model to Investigate the Hemocytocompatibility and Host Cell Activation of Vascular Medical Devices.

In this study, the hemocompatibility of tubes with an inner diameter of 5 mm made of polyvinyl chloride (PVC) and coated with different bioactive conjugates was compared to uncoated PVC tubes, latex tubes, and a stent for intravascular application that was placed inside the PVC tubes. Evaluation of hemocompatibility was done using an in vitro hemodynamic loop model that is recommended by the ISO standard 10993-4. The tubes were cut into segments of identical length and closed to form loops avoiding any gap at the splice, then filled with human blood and rotated in a water bath at 37 °C for 3 hours. Thereafter, the blood inside the tubes was collected for the analysis of whole blood cell count, hemolysis (free plasma hemoglobin), complement system (sC5b-9), coagulation system (fibrinopeptide A), and leukocyte activation (polymorphonuclear elastase, tumor necrosis factor and interleukin-6). Host cell activation was determined for platelet activation, leukocyte integrin status and monocyte platelet aggregates using flow cytometry. The effect of inaccurate loop closure was examined with x-ray microtomography and scanning electron microscopy, that showed thrombus formation at the splice. Latex tubes showed the strongest activation of both plasma and cellular components of the blood, indicating a poor hemocompatibility, followed by the stent group and uncoated PVC tubes. The coated PVC tubes did not show a significant decrease in platelet activation status, but showed an increased in complement and coagulation cascade compared to uncoated PVC tubes. The loop model itself did not lead to the activation of cells or soluble factors, and the hemolysis level was low. Therefore, the presented in vitro hemodynamic loop model avoids excessive activation of blood components by mechanical forces and serves as a method to investigate in vitro interactions between donor blood and vascular medical devices.

In vitro hemo- and cytocompatibility of bacterial nanocelluose small diameter vascular grafts: Impact of fabrication and surface characteristics.

OBJECTIVE: There is an increasing need for small diameter vascular grafts with superior host hemo- and cytocompatibilities, such as low activation of platelets and leukocytes. Therefore, we aimed to investigate whether the preparation of bacterial nanocellulose grafts with different inner surfaces has an impact on in vitro host cytocompatibility. METHODS: We have synthesized five different grafts in a bioreactor, namely open interface surface (OIS), inverted (INV), partially air dried (PAD), surface formed in air contact (SAC) and standard (STD) that were characterized by a different surface roughness. The grafts (length 55 mm, inner diameter 5 mm) were attached to heparinized polyvinyl chloride tubes, loaded with human blood and rotated at 37°C for 4 hours. Then, blood was analyzed for frequencies of cellular fractions, oxidative products, soluble complement and thrombin factors. The results were compared to clinically approved grafts made of polyethylene terephthalate and expanded polytetrafluoroethylene. Additionally, blood platelets were labelled with 111Indium-oxine to visualize the distribution of adherent platelets in the loop by scintigraphy. RESULTS: SAC nanocellulose grafts with the lowest surface roughness exhibited superior performance with <10% leukocyte and <50% thrombocyte loss in contrast to other grafts that exhibited >65% leukocyte and >90% thrombocyte loss. Of note, SAC nanocellulose grafts showed lowest radioactivity with scintigraphy analyses, indicating reduced platelet adhesion. Although the levels of reactive oxygen species and cell free DNA did not differ significantly, the levels of thrombin-antithrombin complexes were lowest in SAC grafts. However, all nanocellulose grafts exhibited enhanced complement activation. CONCLUSION: The systematic variation of the inner surfaces of BNC vascular grafts significantly improves biocompatibility. Especially, SAC grafts exhibited the lowest loss of platelets as well as leukocytes and additionally significantly diminished activation of the coagulation system. Further animal studies are needed to study in vivo biocompatibilities.

Complex Valve Surgery in Elderly Patients: Increasingly Necessary and Surprisingly Feasible.

OBJECTIVES: The increasing proportion of elderly patients in cardiac surgery poses additional challenges for the clinical management and leads to a higher operative risk due to multiple comorbidities of these patients. We reviewed the outcome of patients who were 75 years and older and underwent complex multiple valve surgery at our institution. METHODS: A retrospective review was performed to identify patients who were 75 years and older and underwent multiple valve surgery between January 2011 and May 2016 at our institution. Patients were assigned to one out of four subgroups: combined aortic and mitral valve surgery (group AM), aortic and tricuspid valve surgery (group AT), mitral and tricuspid valve surgery (group MT), and aortic, mitral, and tricuspid valve surgery (group AMT). RESULTS: A total of 311 patients underwent multiple valve surgery, of whom 119 (38.3%) were 75 years and older (median: 78 [25th-75th quartile: 76-80]). The estimated operative mortality (EuroSCORE II) in the overall cohort was 10.7%. The observed 30-day mortality was 4.2% (7% in group AM, 0% in group AT, 2.2% in group MT, 3.8% in group AMT; p = 0.685). Main complications were reexplorative surgery in 16%, adverse cerebrovascular events in 6.7%, prolonged mechanical ventilation in 10.1%, renal replacement therapy in 15.1%, nosocomial pneumonia in 15.1%, and pacemaker implantation in 18.5%. CONCLUSIONS: This study demonstrates the feasibility of complex multiple valve surgery in elderly patients. The observed perioperative mortality was lower than predicted. However, we observed a substantial rate of adverse events; therefore, careful patient selection is required in this high-risk patient population.

Surgical Management of Iatrogenic Left Ventricle Perforation by Chest Tube Insertion.

Chest tube thoracostomy is a standard procedure in every intensive care unit. Although it is regarded as a safe procedure in experienced hands, rare complications do occur. This report describes iatrogenic perforation of the left ventricle after placement of an intercostal catheter and the successful surgical management of this injury. Various operative situations that may arise in relation to iatrogenic perforation of the left ventricle are also discussed, as well as steps to manage this potentially life-threatening complication.

Minimally invasive versus conventional extracorporeal circulation circuits in patients undergoing coronary artery bypass surgery: a propensity-matched analysis.

OBJECTIVES: Minimally invasive extracorporeal circulation circuits provide several advantages compared to conventional extracorporeal circulation circuits. We compared the results of a minimally invasive extracorporeal circulation system with those of conventional extracorporeal circulation system, in patients undergoing isolated coronary artery bypass grafting. METHODS: We identified 753 consecutive patients who underwent coronary artery bypass grafting at our centre between October 2014 and September 2016. These patients were divided into two groups: a minimally invasive extracorporeal circulation group (M, n = 229) and a conventional extracorporeal circulation group (C, n = 524). Baseline parameters, details of cardiac surgery as well as postoperative complications and outcomes were compared by means of a propensity-matched analysis of 180 matched pairs. RESULTS: The median EuroSCORE II was 1.3%. Transfusion requirement of packed red blood cells (p = 0.002) was lower in Group M compared to conventional extracorporeal circulation systems. There were no differences in hospital mortality or in rates of adverse events between the matched groups. Total in-hospital mortality of the cohort was 1.7%. CONCLUSION: The use of minimally invasive extracorporeal circulation is associated with a significantly lower use of blood products after isolated coronary revascularisation. There were no differences concerning duration of surgery, complication rates and mortality between the groups. Therefore, the application of minimally invasive extracorporeal circulation systems should be considered as preferred technique in isolated coronary artery bypass grafting procedures.

Late Onset Valve Dislocation of the Edwards Intuity Rapid-Deployment Bioprosthesis.

Over the last decade, aortic valve replacement with rapid-deployment biologic bioprostheses has become a common alternative to the use of mechanical or biologic stented valves for high-risk patients. A 63-year-old patient underwent uncomplicated valve replacement with the Edwards Intuity valve (Edwards Lifesciences, Irvine, CA). Two months postoperatively, the patient had progressive dyspnea. Echocardiography showed a dislocated aortic valve reaching into the left ventricular outflow tract and impairing the anterior mitral valve leaflet. Both valves were replaced by a conventional stented bioprosthesis. This case report describes the first case of valve migration for the Edwards Intuity Elite rapid-deployment aortic valve and discusses possible explanations.

Root Canal Configuration of Human Permanent Mandibular First Molars of an Indo-Dravidian Population Based in Southern India: An In vitro Study.

AIM: This study aims to analyze root canal configuration of human permanent mandibular first molars of an indo-Dravidian population based in southern India. MATERIALS AND METHODS: A total of 1147 mandibular first permanent molars were collected, cleansed, and stored. The number of roots was recorded, access preparations made, pattern of orifices recorded after pulpal floor debridement, dye injected into the canals using apical negative pressure and subjected to a clearing technique. They were then analyzed using a stereo microscope and the canal configurations recorded (Vertucci). The number of roots, the pattern of orifices and canal configuration were recorded. RESULTS: The pattern of orifices was triangular (87.9%), rectangular (8.5%), C-shaped (3.0%), and two orifice pattern (0.6%). About 95.6% of teeth had two roots, and 4.4% had three roots. The most common canal system configuration in mesial root was Vertucci type IV (52.3%), followed by type II (35%). Root canal configuration of the distal root revealed type I configuration in 62.7%, followed by types II (14.5%) and IV (12.4%). The distolingual root had a type I configuration. CONCLUSION: Awareness of canal configuration, adequate clinical skills, use of specialized techniques of diagnosis, debridement and obturation will pave the way for successful treatment outcomes.