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Interdisciplinary Cardiovascular and... Jun 2024Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, patient-centred approach aimed at expediting recovery, improving clinical outcomes, and reducing...
OBJECTIVES
Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, patient-centred approach aimed at expediting recovery, improving clinical outcomes, and reducing healthcare costs. Initially developed for colorectal surgery, ERAS principles have been successfully applied across various surgical specialties, including cardiac surgery. This study outlines the implementation and certification process of the ERAS program in a tertiary cardiac surgical centre within the Heart-Vessel Department at Lausanne University Hospital.
METHODS
The implementation involved forming a multidisciplinary team, including cardiac surgeons, anaesthesiologists, intensivists, a cardiologist, clinical nurse specialists, and physiotherapists. The ERAS nurse coordinator played a central role in organizing meetings, promoting the program, developing protocols, and collecting data. The certification process required adherence to ERAS guidelines, structured training, and external evaluation. Key phases included pre-ERAS data collection, protocol dissemination, inclusion of the first patients, followed by analysis and full implementation.
RESULTS
Achieving certification required maintaining a compliance rate of over 70% with established protocols. The process involved overcoming various barriers, such as inconsistent practices and the need for multidisciplinary collaboration. In this paper, we provide some solutions to these challenges, including team education, regular meetings, and continuous feedback loops. Preliminary data from the initial cohort showed improvement in early mobilization, opioid use, respiratory complications, and shorter hospital stays.
CONCLUSIONS
The successful implementation of the ERAS program at our institution demonstrates the feasibility and benefits of a structured, multidisciplinary approach in cardiac surgery. Continuous self-assessment and adherence to guidelines are essential for sustained improvement in patient outcomes and healthcare efficiency.
PubMed: 38885412
DOI: 10.1093/icvts/ivae118 -
PloS One 2024There has been a lot of discussion about the role of schools in the transmission of severe acute respiratory coronavirus 2 (SARS-CoV-2) during the coronavirus 2019...
Implementation and effectiveness of non-pharmaceutical interventions, including mask mandates and ventilation, on SARS-CoV-2 transmission (alpha variant) in primary schools in the Netherlands.
There has been a lot of discussion about the role of schools in the transmission of severe acute respiratory coronavirus 2 (SARS-CoV-2) during the coronavirus 2019 (COVID-19) pandemic, where many countries responded with school closures in 2020. Reopening of primary schools in the Netherlands in February 2021 was sustained by various non-pharmaceutical interventions (NPIs) following national recommendations. Our study attempted to assess the degree of regional implementation and effectiveness of these NPIs in South Limburg, Netherlands. We approached 150 primary schools with a structured questionnaire containing items on the implementation of NPIs, including items on ventilation. Based on our registry of cases, we determined the number of COVID-19 cases linked to each school, classifying cases by their source of transmission. We calculated a crude secondary attack rate by dividing the number of cases of within-school transmission by the total number of children and staff members. Two-sample proportion tests were performed to compare these rates between schools stratified by the presence of a ventilation system and mask mandates for staff members. A total of 69 schools responded. Most implemented NPIs were aimed at students, except for masking mandates, which preferentially targeted teachers over students (63% versus 22%). We observed lower crude secondary attack rates in schools with a ventilation system compared to schools without a ventilation system (1.2% versus 2.8%, p<0.01). Mandatory masking for staff members had no effect on the overall crude secondary attack rate (2.0% versus 2.1%, p = 0.03) but decreased the crude secondary attack rate among staff members (2.3% versus 1.7%, p<0.01). Schools varied in their implementation of NPIs, most of which targeted students. Rates of within-school transmission were higher compared to other studies, possibly due to a lack of proper ventilation. Our research may help improve guidance for primary schools in future outbreaks.
Topics: Humans; COVID-19; Netherlands; Schools; Masks; Ventilation; Child; SARS-CoV-2; Surveys and Questionnaires; Students; Pandemics; Male; Female
PubMed: 38885240
DOI: 10.1371/journal.pone.0305195 -
Frontiers in Pediatrics 2024Exchange transfusion therapy is a complex and invasive procedure with a high risk coefficient. This method involves replacing the entire blood of a child with fresh...
BACKGROUND
Exchange transfusion therapy is a complex and invasive procedure with a high risk coefficient. This method involves replacing the entire blood of a child with fresh blood with double circulating blood volume in a short period, typically in 1-2 h. This procedure can cause the body's internal environment to be unstable, which can put newborns under a lot of stress. This stress can lead to many, including abnormal laboratory biochemical examination, low or high blood pressure, and apnea. There is also the possibility of secondary infection and, in severe cases, cardiac arrest. This study investigated the effects of Humidified high-flow nasal cannula (HHFNC) ventilation on hemodynamic stability and oxygenation during exchange transfusion in neonates. Furthermore, the effects on brain metabolism and salivary cortisol during exchange transfusion were also analyzed.
METHODS
In this study, the control group consisted of 45 cases of children who underwent simple blood exchange between 1 May 2017, and 31 December 2019 control group. The observation group consisted of 33 cases of children who underwent blood exchange under HHFNC support between 1 January 2020, and 30 April 2022. The study compared various physiological parameters between the control and the observation group. These included blood gas analysis, pulmonary artery pressure, ejection fraction, invasive mean arterial pressure, heart rate, cerebral oxygenation, intestinal oxygenation, renal oxygenation, and duration of blood exchange. Furthermore, the study also compared the changes in brain metabolic and salivary cortisol indicators between the two groups of children.
RESULTS
The results did not reveal any significant difference in PH, PaO and duration of blood exchange between the control and the observation group. However, the observation group's invasive mean arterial pressure, ejection fraction, cerebral oxygenation, intestinal oxygenation, and renal oxygenation were higher than those of the control group. Furthermore, compared with the control group, the pulmonary artery pressure, heart rate, and PaCO were lower in the observation group. There was a statistically significant difference between the two groups of children in the relevant clinical indicators (total bilirubin, hemoglobin, SPO, etc.) after exchange transfusion. After 1 h of blood exchange and after blood exchange, the salivary cortisol levels of the observation group were lower than the control group. The difference was statistically significant. The NAA/Cho and Cho/Cr values of the two groups of children were also significantly different.
CONCLUSION
During blood exchange, unstable hemodynamics substantially impact organ oxygenation. The results of this study suggest that HHFNC and specific ventilation pressure support can improve the respiratory rate and help maintain blood flow stability and organ oxygenation. This technique can also reduce adverse reactions caused by blood exchange, minimizing patient stress and reducing the impact on brain metabolism.
PubMed: 38884105
DOI: 10.3389/fped.2024.1381808 -
Journal of Thoracic Disease May 2024The efficacy of high-flow nasal cannula (HFNC) in patients extubated after lung resection surgery remains inconclusive. Our objective was to execute a meticulous...
Comparison of high-flow nasal cannula with conventional oxygen therapy for preventing postoperative hypoxemia in patients with lung resection surgery: a systematic review and meta-analysis.
BACKGROUND
The efficacy of high-flow nasal cannula (HFNC) in patients extubated after lung resection surgery remains inconclusive. Our objective was to execute a meticulous systematic meta-analysis to accurately assess the advantages of HFNC compared to conventional oxygen therapy (COT) for patients extubated after lung resection surgery, by examining postoperative hypoxemia and other patient-focused outcomes.
METHODS
We searched PubMed, Embase, the Cochrane Library, Web of Science and Scopus to identify randomized controlled trials (RCTs) from inception to July 2023. We employed the revised Cochrane risk of bias (RoB) tool (2.0) to evaluate the RoB of the included studies, and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method to ascertain the certainty of the pooled effect estimates. The primary outcome was the incidence of postoperative hypoxemia.
RESULTS
Five RCTs (n=564) were included in the ultimate analysis. Utilizing HFNC rather than COT did not reduce the risk of postoperative hypoxemia [relative risk (RR), 0.67; 95% confidence interval (CI): 0.30-1.49; low certainty]. Compared to COT, HFNC may significantly enhance oxygenation index within first 12 hours after extubation in patients with lung resection. There were no significant differences in reintubation rate (RR, 0.25; 95% CI: 0.04-1.54; high certainty), escalation of respiratory support (RR, 0.35; 95% CI: 0.11-1.08; high certainty), change in partial pressure of carbon dioxide (PaCO) within first 24 hours after extubation, hospital length of stay [mean difference (MD), -0.19; 95% CI: -0.44 to 0.06; moderate certainty], and intensive care unit (ICU) length of stay (MD, 0.02; 95% CI: -0.16 to 0.19; high certainty).
CONCLUSIONS
Our meta-analysis suggests that preemptive use of HFNC, instead of COT, in extubated patients following lung resection surgery may not significantly impact postoperative hypoxemia incidence, reintubation rate, escalation of respiratory support, postoperative PaCO difference, hospital and ICU length of stay. However, HFNC may significantly enhance the oxygenation index within the first 12 hours post-extubation following lung resection surgery. To verify the effect of HFNC on this population, additional large-scale, multicenter studies are essential.
PubMed: 38883678
DOI: 10.21037/jtd-23-1758 -
Journal of Thoracic Disease May 2024There is no established standard 3 line treatment for patients with advanced non-small cell lung cancer (NSCLC). Although cytotoxic chemotherapeutic agents that are not...
Treatment rationale and protocol design: an investigator-initiated phase II study of combination treatment of nivolumab and TM5614, a PAI-1 inhibitor for previously treated patients with non-small cell lung cancer.
BACKGROUND
There is no established standard 3 line treatment for patients with advanced non-small cell lung cancer (NSCLC). Although cytotoxic chemotherapeutic agents that are not used as 1 or 2 line treatment are administrated as 3 line treatment, their anti-tumor efficacy is insufficient. Anti-programmed death ligand-1 (PD-L1)/programmed death-1 (PD1) treatment is more effective and less toxic than chemotherapy in anti-PD-L1/PD-1 treatment-naïve patients with NSCLC. Therefore, anti-PD-L1/PD-1 therapy is considered an appropriate 3 line treatment. However, the anti-tumor efficacy is limited in patients previously treated with anti-PD-L1/PD-1 antibody. Today, new drugs are needed to increase the efficacy of anti-PD-L1/PD-1 antibodies.
METHODS
This open-label, single-arm, investigator-initiated phase II study is designed to evaluate combination treatment of nivolumab and TM5614, a plasminogen activator inhibitor (PAI-1) inhibitor as 3 or more line treatment in NSCLC patients who underwent standard treatment. The primary endpoint is the objective response rate and the secondary endpoints are progression-free survival (PFS), overall survival (OS), duration of response (DOR) and safety. Recruitment began in September 2023 and is expected to continue for approximately three years.
DISCUSSION
Currently, there is no standard 3 line treatment for advanced NSCLC, and we hope that the findings of this study will facilitate more effective treatments in this setting. Ethics and dissemination: the study protocol conformed to the ethical principles outlined in the Declaration of Helsinki. All patients will provide written informed consent prior to enrollment. Results will be published in a peer-reviewed publication.
TRIAL REGISTRATION
This study is registered to Japan Registry of Clinical Trials with number: jRCT2061230039 (19/July/2023).
PubMed: 38883673
DOI: 10.21037/jtd-23-1858 -
Journal of Thoracic Disease May 2024Systemic antibiotics are the best treatment options for lung abscesses. However, up to 37% of lung abscesses do not respond to antibiotics and may require additional... (Review)
Review
BACKGROUND AND OBJECTIVE
Systemic antibiotics are the best treatment options for lung abscesses. However, up to 37% of lung abscesses do not respond to antibiotics and may require additional interventions. Percutaneous transthoracic tube drainage (PTTD), endoscopic catheter drainage (ECD) and surgical resection are additional options available when first line therapy with systemic antibiotics are unsuccessful. In this narrative review, we summarize all available interventional procedures, techniques, complications, safety, and contraindications.
METHODS
A literature search was performed using Medline/PubMed from January 1980 to October 2023. Key words: "lung abscess", "pulmonary abscess", "endoscopic drainage", "percutaneous drainage", "tube drainage". Pediatric patients were excluded from this study.
KEY CONTENT AND FINDINGS
PTTD and ECD are fairly safe procedures. Performing PTTD or ECD without delay may shorten the duration of hospital stay. This may lower the burden on health care. Moreover, draining abscesses may relieve discomfort in the clinical symptoms associated with abscesses. The primary factor in choosing ECD over PTTD is the location of the abscess, and the presence of a bronchial airway leading to the abscess for successful ECD. ECD has lower rate of complications and mortality; and similar success rate compared to PTTD. While mortality has been reported with PTTD, ECD appears to be safer according to present data.
CONCLUSIONS
PTTD and ECD are safe procedures, with low complication rates. ECD has a lower complication rate than PTTD does.
PubMed: 38883669
DOI: 10.21037/jtd-23-1561 -
Journal of Thoracic Disease May 2024Serum anion gap (AG) can potentially be applied to the diagnosis of various metabolic acidosis, and a recent study has reported the association of AG with the mortality...
BACKGROUND
Serum anion gap (AG) can potentially be applied to the diagnosis of various metabolic acidosis, and a recent study has reported the association of AG with the mortality of patients with coronavirus disease 2019 (COVID-19). However, the relationship of AG with the short-term mortality of patients with ventilator-associated pneumonia (VAP) is still unclear. Herein, we aimed to investigate the association between AG and the 30-day mortality of VAP patients, and construct and assess a multivariate predictive model for the 30-day mortality risk of VAP.
METHODS
This retrospective cohort study extracted data of 477 patients with VAP from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Data of patients were divided into a training set and a testing set with a ratio of 7:3. In the training set, variables significantly associated with the 30-day mortality of VAP patients were included in the multivariate predictive model through univariate Cox regression and stepwise regression analyses. Then, the predictive performance of the multivariate predictive model was assessed in both training set and testing set, and compared with the single AG and other scoring systems including the Sequential Organ Failure Assessment (SOFA) score, the confusion, urea, respiratory rate (RR), blood pressure, and age (≥65 years old) (CURB-65) score, and the blood urea nitrogen (BUN), altered mental status, pulse, and age (>65 years old) (BAP-65) score. In addition, the association of AG with the 30-day mortality of VAP patients was explored in subgroups of gender, age, and infection status. The evaluation indexes were hazard ratios (HRs), C-index, and 95% confidence intervals (CIs).
RESULTS
A total of 70 patients died within 30 days. The multivariate predictive model consisted of AG (HR =1.052, 95% CI: 1.008-1.098), age (HR =1.037, 95% CI: 1.019-1.055), duration of mechanical ventilation (HR =0.998, 95% CI: 0.996-0.999), and vasopressors use (HR =1.795, 95% CI: 1.066-3.023). In both training set (C-index =0.725, 95% CI: 0.670-0.780) and testing set (C-index =0.717, 95% CI: 0.637-0.797), the multivariate model had a relatively superior predictive performance to the single AG value. Moreover, the association of AG with the 30-day mortality was also found in patients who were male (HR =1.088, 95% CI: 1.029-1.150), and whatever the pathogens they infected (bacterial infection: HR =1.059, 95% CI: 1.011-1.109; fungal infection: HR =1.057, 95% CI: 1.002-1.115).
CONCLUSIONS
The AG-related multivariate model had a potential predictive value for the 30-day mortality of patients with VAP. These findings may provide some references for further exploration on simple and robust predictors of the short-term mortality risk of VAP, which may further help clinicians to identify patients with high risk of mortality in an early stage in the intensive care units (ICUs).
PubMed: 38883665
DOI: 10.21037/jtd-23-1735 -
Journal of Thoracic Disease May 2024Primitive tracheal tumors represent a rare entity whose management, when unresectable, remains challenging. Primary aim of this study was to explore the survival and the...
BACKGROUND
Primitive tracheal tumors represent a rare entity whose management, when unresectable, remains challenging. Primary aim of this study was to explore the survival and the factors influencing prognosis of patients with unresectable primitive tracheal tumor undergoing multimodal treatment integrating interventional bronchoscopy and radiotherapy.
METHODS
This retrospective cohort study was conducted at the University Hospital of Modena (Italy) over a 12-year period (January 2010 to January 2022) analyzing patients with unresectable primary tracheal tumor receiving interventional bronchoscopy treatment followed by radiotherapy. Survival analysis was conducted for the whole population and according to histology, development of metastasis, stent placement and the onset of disease relapse. The raw and independent association between potential risk factor and 5-year mortality and the reported complications were investigated.
RESULTS
A total of 12 patients were included. Five-year survival rate was 42% with a median survival time of 26.7 (interquartile range, 4.1-82) months. Survivors showed a higher prevalence of cystic-adenoid histology (80% 14%), while patients who were dead at 5 years were those with a more advanced T (prevalence of T2: 71% 0%) and a lower response to first line treatment (57% 0%). Treatment complications accounted for stent dislocation (33%) and the onset of granuloma (18%), while no major side effects were reported. The presence of cystic-adenoid histology resulted in significantly improved 5-year survival rate (80% 14%). The onset of distal metastasis, the occurrence of disease relapse and the placement of tracheal stent did not result significantly associated with lower survival. Among analysed variables, only the presence of cystic-adenoid histology resulted independently associated with survival (odds ratio =0.1, P=0.04).
CONCLUSIONS
Multimodal treatment including interventional bronchoscopy and associated radiotherapy for unresectable primary tracheal tumors seems not burdened by significant complications and may provide benefits in terms of survival for those patients with cystic-adenoid histology.
PubMed: 38883644
DOI: 10.21037/jtd-23-738 -
Journal of Thoracic Disease May 2024() is a species of nontuberculous mycobacteria (NTM) that rarely causes infection. It has previously been labeled the most common NTM contaminant. Bronchiectasis is a...
() is a species of nontuberculous mycobacteria (NTM) that rarely causes infection. It has previously been labeled the most common NTM contaminant. Bronchiectasis is a disease characterized by abnormal airway dilation leading to chronic cough, sputum production and pulmonary infections. Patients with bronchiectasis are at higher risk of NTM-lung disease with more pathogenic NTM species including complex (MAC) and (). The relationship between bronchiectasis and less-pathogenic NTM species such as is less well understood. We performed a retrospective study on patients who had isolated from respiratory specimens at UConn Health between May 2, 2010 and October 18, 2022. was isolated 74 times from 56 patients. It was isolated 35 (47.3%) times from 31 patients with bronchiectasis and 39 (52.7%) times from 26 patients without bronchiectasis. Data was available on all mycobacterial cultures sent from May 2 2018 to October 18 2022. Mycobacterial cultures sent from patients with bronchiectasis were significantly more likely to grow than patients without bronchiectasis (4.3% . 1.6%, P=0.007). Furthermore, when considered at the patient level, there remained a significant increased rate of isolation among patients with bronchiectasis (7.1% . 2.2%, P<0.001). We then looked at past and future isolation of more pathogenic NTM species and found a non-statistically increased rate of isolation of more pathogenic NTM species including MAC and in patients with bronchiectasis (45.2% . 29%, P=0.09). Based on our results, isolation of should raise suspicion of chronic airway disease and defects in host immune response, such as those seen in bronchiectasis. Furthermore, isolation of may suggest increased risk of infection with more pathogenic NTM species such as MAC and .
PubMed: 38883635
DOI: 10.21037/jtd-23-1648 -
Journal of Thoracic Disease May 2024Airway intervention, including stenting, can rapidly improve a patient's respiratory condition, but the procedure requires highly specialized techniques and expertise....
BACKGROUND
Airway intervention, including stenting, can rapidly improve a patient's respiratory condition, but the procedure requires highly specialized techniques and expertise. Therefore, educating young endoscopists and passing on the techniques are major issues. However, the best way to educate new doctors on these techniques remains unclear. This study analyzed our educational system for airway intervention and its outcomes.
METHODS
Patients who underwent airway intervention regarding airway stents under general anesthesia in our department between January 2010 and September 2023 were included. The outcomes of interventions related to airway stents in our hospital were evaluated retrospectively, including from an educational perspective.
RESULTS
A total of 96 patients (76 undergoing stenting for airway stenosis, 8 stenting for airway-esophageal fistula, and 12 stent removal) were analyzed. The median experience level of the main physician was 5 (range, 1-17) years, and that of the supervising physician was 18 (range, 5-23) years. The median number of physicians who participated in the interventions was four. A rigid bronchoscope was used in 86.5% of cases. The procedure success rate was 95.8%. Intraoperative complications occurred in 8.3% and postoperative complications in 10.5% of cases, and there was 1 procedure-related death (1.3%). In the analysis of factors related to the development of complications, the years of experience of the main physician had no influence.
CONCLUSIONS
These findings indicate that our method of airway intervention is safe. Young endoscopists were able to master the technique by gaining experience under the supervision of experts.
PubMed: 38883624
DOI: 10.21037/jtd-24-89