Search

This prospective study explores health-related quality of life (EQ-5D-5L), event-related distress (IES-R), and depression (CES-D) after cardiac surgery during three COVID-19 lockdowns imposed in the UK. Overall, 253 patients (Lockdown 1 n = 196; 2 n = 45; 3 n = 12) completed the above-mentioned questionnaires at baseline, 1 week after discharge, and 6 weeks and 6 and 12 months after surgery. While EQ-5D-5L values were similar across all cohorts, those who underwent surgery during Lockdowns 2 and 3 had higher IES-R scores at 1 year and higher IES-R and CES-D baseline scores, respectively. Generally, increased distress, worse depression, and poorer HRQoL were observed in women. Registration ClinicalTrials.gov: NCT04366167 [ABSTRACT FROM AUTHOR]

Aims The outbreak of COVID-19 was potentially stressful for everyone and possibly heightened in those having surgery. We sought to explore the impact of the pandemic on recovery from cardiac surgery. Methods and results A prospective observational study of 196 patients who were ≥18years old undergoing cardiac surgery between March 23 and July 4, 2020 (UK lockdown) was conducted. Those too unwell or unable to give consent/complete the questionnaires were excluded. Participants completed (on paper or electronically) the impact of event [Impact of Events Scale-revised (IES-R)] (distress related to COVID-19), depression [Centre for Epidemiological Studies Depression Scale (CES-D)], and EQ-5D-5L [(quality of life, health-related quality of life (HRQoL)] questionnaires at baseline, 1 week after hospital discharge, and 6 weeks, 6 months and 1 year post-surgery. Questionnaire completion was >75.0% at all timepoints, except at 1 week (67.3%). Most participants were male [147 (75.0%)], white British [156 (79.6%)] with an average age 63.4years. No patients had COVID-19. IES-R sand CES-D were above average at baseline (indicating higher levels of anxiety and depression) decreasing over time. HRQoL pre-surgery was high, reducing at 1 week but increasing to almost pre-operative levels at 6 weeks and exceeding pre-operative levels at 6 months and 1 year. IES-R and CES-D scores were consistently higher in women and younger patients with women also having poorer HRQoL up to 1-year after surgery. Conclusions High levels of distress were observed in patients undergoing cardiac surgery during the COVID-19 pandemic with women and younger participants particularly affected. Psychological support pre- and post-operatively in further crises or traumatic times should be considered to aid recovery. Registration Clinicaltrials.gov ID:NCT04366167. [ABSTRACT FROM AUTHOR]

Previous studies have shown that differences in experimental design factors may alter the potency of genotoxic compounds in in vitro genotoxicity tests. Most of these studies used traditional statistical methods based on the lowest observed genotoxic effect levels, whereas more appropriate methods, such as the benchmark dose (BMD) approach, are now available to compare genotoxic potencies under different test conditions. We therefore investigated the influence of two parameters, i.e. cell type and exposure duration, on the potencies of two known genotoxicants [aflatoxin B1 and ethyl methanesulfonate (EMS)] in the in vitro micronucleus (MN) assay and comet assay (CA). Both compounds were tested in the two assays using two cell types (i.e. CHO-K1 and TK6 cells). To evaluate the effect of exposure duration, the genotoxicity of EMS was assessed after 3 and 24 h of exposure. Results were analyzed using the BMD covariate approach, also referred to as BMD potency ranking, and the outcome was compared with that of more traditional statistical methods based on lowest observed genotoxic effect levels. When comparing the in vitro MN results obtained in both cell lines with the BMD covariate approach, a difference in potency was detected only when EMS exposures were conducted for 24 h, with TK6 cells being more sensitive. No difference was observed in the potency of both EMS and aflatoxin B1 in the in vitro CA using both cell lines. In contrast, EMS was more potent after 24 h exposure compared with a 3 h exposure under all tested conditions, i.e. in the in vitro MN assay and CA in both cell lines. Importantly, for several of the investigated factors, the BMD covariate method could not be used to confirm the differences in potencies detected with the traditional statistical methods, thus highlighting the need to evaluate the impact of experimental design factors with adequate approaches. [ABSTRACT FROM AUTHOR]

Background Postoperative morbidity places considerable burden on health and resources. Thus, strategies to identify, predict, and reduce postoperative morbidity are needed. Aims To identify and explore existing preoperative risk assessment tools for morbidity after cardiac surgery. Methods Electronic databases (including MEDLINE, CINAHL, and Embase) were searched to December 2020 for preoperative risk assessment models for morbidity after adult cardiac surgery. Models exploring one isolated postoperative morbidity and those in patients having heart transplantation or congenital surgery were excluded. Data extraction and quality assessments were undertaken by two authors. Results From 2251 identified papers, 22 models were found. The majority (54.5%) were developed in the USA or Canada, defined morbidity outcome within the in-hospital period (90.9%), and focused on major morbidity. Considerable variation in morbidity definition was identified, with morbidity incidence between 4.3% and 52%. The majority (45.5%) defined morbidity and mortality separately but combined them to develop one model, while seven studies (33.3%) constructed a morbidity-specific model. Models contained between 5 and 50 variables. Commonly included variables were age, emergency surgery, left ventricular dysfunction, and reoperation/previous cardiac surgery, although definition differences across studies were observed. All models demonstrated at least reasonable discriminatory power [area under the receiver operating curve (0.61–0.82)]. Conclusion Despite the methodological heterogeneity across models, all demonstrated at least reasonable discriminatory power and could be implemented depending on local preferences. Future strategies to identify, predict, and reduce morbidity after cardiac surgery should consider the ageing population and those with minor and/or multiple complex morbidities. [ABSTRACT FROM AUTHOR]

Background: Health-related quality of life (HRQoL) is important in determining surgical success, particularly from the patients' perspective.Aims: To identify predictors for HRQoL outcome after cardiac surgery in order to identify potentially modifiable factors where interventions to improve patient outcomes could be targeted.Methods: Electronic databases (including MEDLINE, CINAHL, Embase) were searched between January 2001 and December 2020 for studies determining predictors of HRQoL (using a recognised and validated tool) in adult patients undergoing cardiac surgery. Data extraction and quality assessments were undertaken and data was summarised using descriptive statistics and narrative synthesis, as appropriate.Results: Overall, 3924 papers were screened with 41 papers included in the review. Considerable methodological heterogeneity between studies was observed. Most were single-centre (75.6%) prospective observational studies (73.2%) conducted in patients undergoing coronary artery bypass graft (CABG) (n = 51.2%) using a version of the SF-36 (n = 63.4%). Overall, 103 independent predictors (62 pre-operative, five intra-operative and 36 post-operative) were identified, where 34 (33.0%) were reported in more than one study. Potential pre-operative modifiable predictors include alcohol use, BMI/weight, depression, pre-operative quality of life and smoking while in the post-operative period pain and strategies to reduce post-operative complications and intensive care and hospital length of stay are potential therapeutic targets.Conclusion: Despite a lack of consistency across studies, several potentially modifiable predictors were identified that could be targeted in interventions to improve patient or treatment outcomes. This may contribute to delivering more person-centred care involving shared decision-making to improve patient HRQoL after cardiac surgery. [ABSTRACT FROM AUTHOR]

Aims and Objectives: In order to retain and develop pre‐doctoral and doctoral staff, we sought to establish and implement a model for supporting postdoctoral clinical academic careers at our hospital. Background: Doctorally‐prepared nurses can raise clinical practice standards, but there is a deficit of career opportunities and post‐doctoral positions. This will inevitably impact delivering the evidence for improving patient outcomes and service delivery. It is therefore imperative that post‐doctoral nursing and allied professional post‐doctoral clinical academic career opportunities are developed and embedded in practice. Design: We describe the development and implementation of a model to provide and embed post‐doctoral clinical academic roles at our hospital. Methods: A multidisciplinary group devised the model which was approved by the Hospital Executive Board. Results: The model includes having a bespoke plan for each individual, planning the post‐doctoral role at time of PhD planning, providing 1 day a week protected research time for a minimum of 12 months after PhD completion, having an appropriate honorary academic contract at a partner University, and providing integrated clinical and academic supervision throughout. Other key components include senior clinical and Executive Board support and an existing vibrant research culture at our organisation. Conclusions: The St Bartholomew's Hospital model, focusing on individualised posts integrating clinical and academic roles to address service needs, offers a novel approach to supporting post‐doctoral clinical academic careers in a clinical setting. Relevance to clinical practice: Since doctorally‐prepared nurses can raise clinical practice standards we developed a sustainable infrastructure to increase our postdoctoral nursing and allied professional workforce. This model could provide a framework for other hospitals to embed postdoctoral clinical academic careers in practice. [ABSTRACT FROM AUTHOR]

Background: Early studies conclude patients with Covid-19 have a high risk of death, but no studies specifically explore cardiac surgery outcome. We investigate UK cardiac surgery outcomes during the early phase of the Covid-19 pandemic.Methods: This retrospective observational study included all adult patients undergoing cardiac surgery between 1st March and 30th April 2020 in nine UK centres. Data was obtained and linked locally from the National Institute for Cardiovascular Outcomes Research Adult Cardiac Surgery database, the Intensive Care National Audit and Research Centre database and local electronic systems. The anonymised datasets were analysed by the lead centre. Statistical analysis included descriptive statistics, propensity score matching (PSM), conditional logistic regression and hierarchical quantile regression.Results: Of 755 included individuals, 53 (7.0%) had Covid-19. Comparing those with and without Covid-19, those with Covid-19 had increased mortality (24.5% v 3.5%, p < 0.0001) and longer post-operative stay (11 days v 6 days, p = 0.001), both of which remained significant after PSM. Patients with a pre-operative Covid-19 diagnosis recovered in a similar way to non-Covid-19 patients. However, those with a post-operative Covid-19 diagnosis remained in hospital for an additional 5 days (12 days v 7 days, p = 0.024) and had a considerably higher mortality rate compared to those with a pre-operative diagnosis (37.1% v 0.0%, p = 0.005).Conclusions: To mitigate against the risks of Covid-19, particularly the post-operative burden, robust and effective pre-surgery diagnosis protocols alongside effective strategies to maintain a Covid-19 free environment are needed. Dedicated cardiac surgery hubs could be valuable in achieving safe and continual delivery of cardiac surgery. [ABSTRACT FROM AUTHOR]

Background: Post-operative morbidity affects up to 36% of cardiac surgical patients. However, few countries reliably record morbidity outcome data, despite patients wanting to be informed of all the risks associated with surgery. The Cardiac Post-Operative Morbidity Score (C-POMS) is a new tool for describing and scoring (0-13) total morbidity burden after cardiac surgery, derived by noting the presence/absence of 13 morbidity domains on days 3, 5, 8 and 15. Identifying modifiable C-POMS risk factors may suggest targets for intervention to reduce morbidity and healthcare costs. Thus, we explored the association of C-POMS with previously identified predictors of post-operative morbidity. Methods: A systematic literature review of pre-operative risk assessment models for post-operative morbidity was conducted to identify variables associated with post-operative morbidity. The association of those variables with C-POMS was explored in patients drawn from the original C-POMS study (n = 444). Results: Seventy risk factors were identified, of which 56 were available in the study and 49 were suitable for analysis. Numbers were too few to analyse associations on D15. Thirty-three (67.3%) and 20 (40.8%) variables were associated with C-POMS on at least 1 or 2 days, respectively. Pre-operative albumin concentration, left ventricular ejection fraction and New York Heart Association functional class were associated with C-POMS on all days. Of the 16 independent risk factors, pre-operative albumin and haemoglobin concentrations and weight are potentially modifiable. Conclusions: Different risk factors are associated with total morbidity burden on different post-operative days. Preoperative albumin and haemoglobin concentrations and weight were independently predictive of post-operative total morbidity burden suggesting therapeutic interventions aimed at these might reduce both post-operative morbidity risk and health-care costs in patients undergoing cardiac surgery. [ABSTRACT FROM AUTHOR]

Background: Pre-operative anaemia is associated with mortality and red blood cell (RBC) transfusion requirement after cardiac surgery. However, the effect on post-operative total morbidity burden (TMB) is unknown. We explored the effect of pre-operative anaemia on post-operative TMB. Methods: Data were drawn from the Cardiac Post-Operative Morbidity Score (C-POMS) development study (n = 442). C-POMS describes and quantifies (0-13) TMB after cardiac surgery by noting the presence/absence of 13 morbidity domains on days 3 (D3), 5 (D5), 8 (D8) and 15 (D15). Anaemia was defined as a haemoglobin concentration below 130 g/l for men and 120 g/l for women. Results: Most patients were White British (86.1%) and male (79.2%) and underwent coronary artery bypass surgery (67.4%). Participants with pre-operative anaemia (n = 137, 31.5%) were over three times more likely to receive RBC transfusion (OR 3.08, 95%CI 1.88-5.06, p < 0.001), had greater D3 and D5 TMB (5 vs 3, p < 0.0001; 3 vs 2, p < 0.0001, respectively) and remained in hospital 2 days longer (8 vs 6 days, p < 0.0001) than non-anaemic patients. Transfused patients remained in hospital 5 days longer than non-transfused patients (p < 0.0001), had higher TMB on all days (all p < 0.001) and suffered greater pulmonary, renal, GI, neurological, endocrine and ambulation morbidities (p 0.026 to <0.001). Pre-operative anaemia and RBC transfusion were independently associated with increased C-POMS score. Conclusions: Pre-operative anaemia and RBC transfusion are independently associated with increased post-operative TMB. Understanding TMB may assist in post-operative patient management to reduce morbidity. We recommend the use of the C-POMS tool as a standard outcome tool in further studies. [ABSTRACT FROM AUTHOR]

The purpose of this systematic review is to synthesize available studies on sleep health characteristics in adults of African descent with or at risk for cardiometabolic conditions. PubMed, PsycINFO, CINAHL, and Web of Science were searched for original research studies on subgroups of African descent with at least one cardiometabolic risk factor. Studies published in English with measured sleep characteristics were included. Studies focused on participants with severe psychiatric illness, night shift workers, or with a pharmacologic sleep treatment focus were excluded. The risk for bias was assessed using the NHLBI 2021 Quality Assessment Tool. Two reviewers independently synthesized the results before reaching a consensus. Out of 340 studies screened, 35 studies were included. There were 631,756 participants with an average age of 44.3 combined (SD = 16.5) (53% female and 22% Black). Disparities in sleep health characteristics and cardiometabolic health among African American adults were found. Markers of poor cardiometabolic health were associated with disordered sleep. While the studies in this review captured key factors, the study measurement methods were inconsistent, and African Caribbean Americans were underrepresented. The studies demonstrated the intersectionality of poor sleep characteristics, cardiometabolic risk factors, and racial/ethnic groupings. Clinicians should consider these findings when providing care. [ABSTRACT FROM AUTHOR]

Background Complementary and alternative medicines ( CAM) use is increasing, particularly in patients with a cancer diagnosis. When taken alone, many CAM are safe, but when taken concurrently with chemotherapy, radiotherapy or prior to surgery, serious side effects or interactions may occur. Aim To determine the magnitude of CAM use among patients receiving chemotherapy at a metropolitan hospital. To assess the impact of pharmacists providing patients with personalised evidence-based information regarding CAM safety with conventional anticancer treatment. Method Between April and June 2013 all patients commencing their first cycle of intravenous chemotherapy on the Chemotherapy Day Unit were interviewed by the pharmacist to evaluate ingested and injected CAM use. All patients using CAM were given comprehensive, personalised verbal information on safety and potential drug interactions with their conventional treatment. Consenting patients were followed up to evaluate adherence to pharmacist recommendations. Results A total of 152 patients were interviewed regarding CAM use; 39% (95% confidence interval ( CI) 32-47%) of patients were taking CAM; median number taken was 2 (range: 1-11) and total number of CAM was 141; 41% of CAM investigated had identified interactions with conventional anticancer treatments; 98% (95% CI 96-100%) of patients followed pharmacist recommendations relating to the safety of (dis)continuing CAM. Conclusion Nearly 40% of patients commencing chemotherapy were concurrently taking CAM. Of the investigated CAM, over 40% had identified interactions, presenting a significant risk to patients both in terms of toxicities and treatment efficacy. Provision of personalised advice from an oncology pharmacist is a highly effective intervention to improve patient safety. [ABSTRACT FROM AUTHOR]

Aims and objectives: To examine the effectiveness of cognitive interventions after general anaesthesia to improve cognitive functioning. Background: The number of surgical procedures performed worldwide is large and growing. Postoperative cognitive dysfunction is a common complication associated with poor postoperative outcomes. A variety of cognitive interventions have been developed to maintain or improve cognitive function in one or more cognitive domains. Cognitive interventions have shown to be effective in healthy older populations, those with mild cognitive impairment, and those with heart failure. The impact of cognitive interventions in surgical patients after general anaesthesia is a relatively new focus of research and is therefore less well established. Methods: Seven bibliographic databases were searched in relation to 'surgery' and 'cognitive interventions'; no date or language limits were imposed. Studies including adult patients who were scheduled for, or who had undergone surgery under general anaesthesia, had a baseline cognitive assessment using a validated measurement, and had engaged with any cognition‐based intervention were included. Full‐text review for inclusion, quality assessment and data extraction were undertaken independently by two authors. This study is reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta‐Analyses guidelines. Results: A total of 550 papers were identified for possible inclusion, of which nine met the inclusion criteria and were included in the review. The majority were randomised controlled trials (RCTs) (n = 6 [66.7%]). Four studies used computerised cognitive interventions, while five used traditional cognitive interventions. Most of the studies used multi‐domain cognitive training focusing on two or more domains (n = 7 [77.8%]) while two studies used single‐domain cognitive training. Memory (n = 7 [77.8%]) and attention (n = 5 [55.6%]) were the cognitive domains most often targeted during the intervention. Conclusions: The use of cognitive interventions demonstrated some efficacy in improving cognitive function after general anaesthesia, particularly those targeting memory. Relevance for clinical practice The findings of this review suggest that cognitive interventions show promise at improving cognitive performance in patients with POCD and could be usefully implemented in clinical practice to improve patient outcomes. [ABSTRACT FROM AUTHOR]

A 54-year-old male with relapsed primary cerebral lymphoma and normal renal function was treated with methotrexate (MTX) 3 g/m2 monthly by intravenous infusion. Throughout treatment the patient self-administered a complementary medicine (Jason Winter’s chlorophyll®), which he was advised to cease during methotrexate treatment due to the potential for unknown interactions. For the first four cycles, chlorophyll was ceased two days prior to commencement of methotrexate and withheld until clearance. These cycles were administered without complication, and the methotrexate level reduced to <0.05 µmol/L within three days of each dose. Prior to cycle 5, chlorophyll was not ceased and there were no changes to concomitant medications. A literature search found no documented interactions between methotrexate and chlorophyll and the chemotherapy was administered without a delay in treatment. The methotrexate level three days post-administration was 0.36 µmol/L and did not reduce to <0.05 µmol/L until day 10. Consequently, from cycles 6 to 12, the methotrexate dose was halved, and the patient ceased chlorophyll 48 h prior to methotrexate administration until clearance. There were no further episodes of delayed methotrexate clearance. No impurities were detected in a sample of Jason Winter’s chlorophyll®. It is therefore likely that the patient’s delayed methotrexate clearance was due to an interaction with chlorophyll. It is recommended that such chlorophyll containing preparations be avoided in patients treated with methotrexate. [ABSTRACT FROM PUBLISHER]

There is much current interest in walking as a social and physiological practice in disciplines from literature to geography, from anthropology to performance studies. 'Walking Studies' impact Shakespearean scholarship and in particular work relating to Shakespeare-freighted sites such as Stratford-upon-Avon, where the loaded discourses of tourism and personal encounter are predominant in the practical experience of visitors. This article asks what it might mean, either for the individual or the collective, to 'walk with Shakespeare' and whether the 'Shakespeare' that we locate in these experiences is always already a construct, fashioned to feed the demands of a national economy and the gross national product by drawing millions of visitors to an otherwise fairly nondescript Midlands market town. It explores the possibility that walking with 'Shakespeare' may mean walking with an available icon but not with the complex textual, performative, and historical Shakespeares at the heart of academic scholarship. [ABSTRACT FROM AUTHOR]

Abstract: Background: A substantial proportion of patients suffer prolonged length of intensive care unit stay (PLOS) or prolonged mechanical ventilation (PMV) following coronary artery bypass grafting (CABG). Identifying factors associated with PLOS and PMV would aid in patient risk stratification. We sought to identify the factors associated with PLOS and PMV following CABG. Methods: Participants were patients undergoing first-time elective CABG. All were observed until discharge and clinical data were collected on a standardized proforma. PLOS and PMV were defined a priori as >2days and >12h respectively, based on centre norms. Results: Of the 439 patients in the study, 105 (23.9%) had PLOS and 111 (25.2%) had PMV. Independent predictors of PMV were age, diabetes, previous myocardial infarction (MI), New York Heart Association (NYHA) class and statin use. The only independent predictor of PLOS was the duration of preceding hypertension. Conclusion: The factors associated with PMV and PLOS in our study are easily attainable, routine clinical details and may be built into bed management algorithms. Confirmation of the association of preceding hypertension and subsequent investigation of the possible mechanism mediating this association, is suggested. [Copyright &y& Elsevier]

Abstract: Objective: To develop a tool for identifying and quantifying morbidity following cardiac surgery (cardiac postoperative morbidity score [C-POMS]). Study Design and Setting: Morbidity was prospectively assessed in 450 cardiac surgery patients on postoperative days 1, 3, 5, 8, and 15 using POMS criteria (nine postoperative morbidity domains in general surgical patients) and cardiac-specific variables (from expert panel). Other morbidities were noted as free text and included if prevalence was more than 5%, missingness less than 5%, and mean expert-rated severity-importance index score more than 8. Construct validity was assessed by expert panel review, Cronbach’s alpha (internal consistency), and linear regression (predictive ability of C-POMS for length of stay [LOS]). Results: A 13-domain model was derived. Internal consistency (>0.7) on D3–D15 permits use as a summative score of total morbidity burden. Mean C-POMS scores were 3.4 (D3), 2.6 (D5), 3.4 (D8), and 3.8 (D15). Patient LOS was 4.6 days (P =0.012), 5.3 days (P =0.001), and 7.6 days (P =0.135) longer in patients with C-POMS-defined morbidity on D3, D5, D8, and D15, respectively, than in those without. For every unit increase in C-POMS summary score, subsequent LOS increased by 1.7 (D3), 2.2 (D5), 4.5 (D8), and 6.2 (D15) days (all P =0.000). Conclusion: C-POMS is the first validated tool for identifying total morbidity burden after cardiac surgery. However, further external validation is warranted. [Copyright &y& Elsevier]

BACKGROUND: The association of red blood cell (RBC) storage on morbidity outcome after cardiac surgery is debated. We sought to clarify the association of the age of transfused blood on outcome in patients undergoing cardiac surgery. STUDY DESIGN AND METHODS: Data were drawn from a prospective, observational cohort study of morbidity outcome in patients undergoing cardiac surgery. Blood transfusion data were obtained retrospectively via the Trust blood bank electronic records. Old blood was defined as more than 14 days old. The primary outcome measure was postoperative length of stay (PLOS). Secondary outcome measures included renal failure and morbidity as defined within the postoperative morbidity survey. RESULTS: A total of 176 (39.6%) of 444 participants received a blood transfusion. Patients transfused with new blood had a reduced PLOS compared with patients receiving exclusively old or any old blood (old blood ± new blood; 7 days vs. 8 days, p = 0.04 and vs. 10 days, p = 0.002, respectively). In patients who only had 1 unit transfused, PLOS was longer in those receiving only old blood compared with those receiving only new blood (8 days vs. 6 days, p = 0.02) with a 3.8-fold risk of longer stay. Compared with patients receiving exclusively new blood, patients receiving any old blood had a higher incidence of new renal complications (65.7% vs. 43.9%, p = 0.008). Each 1-day increase in storage was associated with a 7% increase in risk of new renal complications. CONCLUSION: Our data support previous suggestions of an association between transfusion of older RBCs and poorer outcome in cardiac surgery patients. Randomized controlled trials are required to determine the true causal nature of any such association. [ABSTRACT FROM AUTHOR]

Abstract: Large increases in inflammatory markers, particularly IL-6, occur after cardiac surgery. However, despite interventions to reduce the inflammatory response, great variability still remains which could in part be attributable to genetic predisposition. Since increased IL-6 levels following surgery are also associated with poorer outcome we sought to determine whether baseline and post-operative levels of Interleukin-6 (IL-6) and functional common variants of the Interleukin-6 (IL6) gene are associated with post-operative outcome following coronary artery bypass grafting (CABG). Caucasian patients undergoing first-time elective CABG were studied. IL-6 levels were measured pre-, 6h and 24h following surgery and genotypes for IL6 gene variants −174G>C and −572G>C were obtained. Clinical data was collected daily until patient discharge. Patient outcome was categorised as with (ICUC, n =177) and without (NICUC, n =189) a post-operative complication during the ICU period and with (POC, n =215) and without (NC, n =151) a post-operative complication during hospitalisation. IL-6 levels pre- and at 24h were greater in POC and ICUC than NC and NICUC, respectively. Pre- IL-6 levels independently predicted (for 1 standard deviation increase in log IL-6) POC (OR 1.4, 95% CI 1.1–1.7, p =0.008) and ICUC (OR 1.3, 95% CI 1.0–1.6, p =0.02) outcomes. Overall, the IL6-572G>C had an effect over time on IL-6 levels (p =0.04) and on IL-6 levels in NC (P=0.008) and NICUC (p =0.006). However, no associations were found with the IL6 −572G>C or −174G>C variants on IL-6 levels at individual time-points or by outcome group. Thus, in conclusion, elevated pre-operative IL-6 levels, but not IL6 gene variants predict poor patient outcome following CABG. [Copyright &y& Elsevier]

Objective: To determine whether cardiothoracic ratio (CTR), within the range conventionally considered normal, predicted prognosis in patients undergoing coronary angiography. Design: Cohort study with a median of 7-years follow-up. Setting: Consecutive patients undergoing coronary angiography at Barts and The London National Health Service (NHS) Trust. Subjects: 1005 patients with CTRs measured by chest radiography, and who subsequently underwent coronary angiography. Of these patients, 7.3% had a CTR ⩾0.5 and were excluded from the analyses. Outcomes: All-cause mortality and coronary event (non-fatal myocardial infarction or coronary death). Adjustments were made for age, left ventricular dysfunction, ACE inhibitor treatment, body mass index, number of diseased coronary vessels and past coronary artery bypass graft. Results: The risk of death was increased among patients with a CTR in the upper part of the normal range. In total, 94 (18.9%) of those with a CTR below the median of 0.42 died compared with 120 (27.8%) of those with a CTR between 0.42 and 0.49 (log rank test p< 0.001). After adjusting for potential confounders, this increased risk remained (adjusted HR 1.45, 95% CI 1.03 to 2.05). CTR, at values below 0.5, was linearly related to the risk of coronary event (test for trend p=0.024). Conclusion : In patients undergoing coronary angiography, CTR between 0.42 and 0.49 was associated with higher mortality than in patients with smaller hearts. There was evidence of a continuous increase in risk with higher CTR. These findings, along with those in healthy populations, question the conventional textbook cut-off point of ⩾0.5 being an abnormal CTR. [ABSTRACT FROM AUTHOR]

The deletion (D) rather than insertion (I) allele of the angiotensin-converting enzyme (ACE) gene is associated with greater ACE activity. We examined: (1) the influence of posture change (recumbent to seated) and acute exercise on serum ACE and angiotensin II (Ang II) activity; (2) the relationship between ACE and Ang II levels; and (3) the influence of ACE genotype on changes in ACE and Ang II levels with posture and exercise. Recreationally active young male Caucasians (10 each of II, ID and DD genotypes) rested for 35 min supine then 15 min upright, took 20 min bicycle ergometric exercise at 70% maximum oxygen uptake, then rested for 40 min. Samples were taken throughout for ACE activity and Ang II levels. Supine ACE levels were dependent upon ACE genotype [24.8 (5.7), 26.9 (4.5), 45.5 (6.4) nmol His-Leu ml-1 min-1; II, ID, DD, respectively; P<0.00005] and thereafter. ACE activity rose with assumption of a seated posture [from 32.4 (10.9) nmol His-Leu ml-1 min-1 to 35.0 (11.5) nmol His-Leu ml-1 min-1, P<0.00001], the absolute rise being independent of genotype [3.22 (1.92), 1.6 (1.6), 2.4 (2.3) nmol His-Leu ml-1 min-1; II, ID, DD; P=0.22], unlike percentage change [12.8 (6.8), 5.6 (5.5), 5.3 (5.0)%; II, ID, DD; P<0.01, and P=0.004 for II vs presence of the D allele]. A further genotype-independent rise occurred with exercise [+2.9 (3.7) units, P<0.0003]. An associated rise in Ang II levels [30.3 (15.9), or 2587.9 (489.76)%, P<0.00001] was independent of ACE genotype or activity. Upright posture increases ACE activity, and this may be influenced by ACE genotype. ACE activity and Ang II levels rise independently with exercise in a non-genotype-dependent fashion. [ABSTRACT FROM AUTHOR]

Part I. Focuses on the representation of beggars in the plays written by John Suckling, Richard Brome and James Shirley. Notion of the evil counsel in 'The Goblins'; Characterization of a landowner in 'A Jovial Crew'; Establishment of an alternative society in 'The Sisters.'

Evaluates the effect of dissociation on intrusive memories. Assignment of the subjects to watch a stressful film; Level of distress observed among the subjects; Dual-representation theory of post-traumatic stress disorder.

Discusses ways in which the associations of Lucy Hay, nee Lucy Percy, the Countess of Carlisle, with Platonism and performance influenced public plays during the 17th century. Representation of Hay in contemporary writings as being the chief rival of Henrietta Maria, the French consort of England's Charles I; Henrietta Maria's influence on Caroline cultural production.

A review of health professional attitudes and patient perceptions on ‘inappropriate’ accident and emergency attendances. The implications for current minor injury service provision in England and Wales Increasing attendances in accident and emergency (A and E) departments in the United Kingdom have been attributed to a greater number of patients presenting with minor injuries. A and E staff believe this type of patient is suitable for primary care, and is ‘inappropriate’ for A and E management. Thus, A and E staff find ‘inappropriate’ attenders time-consuming and unrewarding, and are less motivated to help them, whilst ‘inappropriate’ patients believe they have attended the appropriate service for their medical needs and expectations. This review examines research into health professional and patient attitudes towards ‘inappropriate’ attendances in accident and emergency. It identifies a discrepancy between health professional and patient perspectives regarding ‘inappropriate’ attendances. However, the change in accident and emergency services with the development of minor injury units and nurse practitioners within A and E to treat minor injury patients away from the mainstream A and E service, appears to be based on the professional attitude of what constitutes an appropriate A and E attendance, and not on the patients’ perspective. As negative attitude formation towards ‘inappropriate’ A and E attendances has occurred, there is concern that such attitudes could remain or develop again in the new units. Patients are generally not medically trained and may experience difficulty in ascertaining the severity of their own condition and attending the ‘appropriate’ service, as defined by trained professionals. This is exacerbated by the unclear boundaries and roles of minor injury units, nurse practitioners and general practitioners in minor injury... [ABSTRACT FROM AUTHOR]

Reviews Ben Jonson's prologue `A Tale of a Tub,' taken from the book `Selected Plays of Ben Johnson, edited by Martin Butler.

Focuses on Ben Jonson's 1629 play `The New Inn' and its relationship to contemporary Caroline politics, in particular theatrical politics and the controversy surrounding the question of women actors. Need to reread the play from the vantage point of social history; Play's role as a promoter of female performance; Parliamentary debate in the wake of controversy over the Petition of Right.

Background: Cancer patients are increasingly using complementary and alternative medicines (CAM). Oncology pharmacists need to be able to discuss CAM use with patients, and identify potential interactions with conventional cancer therapies. At the study oncology hospital, the Drug Information (DI) centre responds to around 25 complex inquiries on CAM each month. Aim: To highlight the role of DI pharmacists in advising cancer patients and health professionals on the safe use of CAM with conventional cancer therapies. Method: 3 case studies on CAM researched by the DI centre are presented. Conclusion: DI pharmacists provide safe and informed advice to health professionals and patients on CAM use with conventional cancer therapies [ABSTRACT FROM AUTHOR]

Human physical performance is influenced by genetic factors. A variation in the human angiotensin I-converting enzyme (ACE) gene has been identified, in which the insertion (I) variant may be associated with elite endurance performance, and the deletion (D) variant seems overrepresented amongst elite sprinters and short-distance swimmer status. We might thus anticipate I-allele frequency to be elevated amongst swimmers competing over very much greater distances, and have examined this hypothesis. Thirty-five truly elite very-long-distance swimmers were classified as better at 1- to 10-km distances (n=19, SLD group) or those best at 25-km races (n=16, LLD group). Genotype frequencies (II versus ID versus DD) differed between the two groups: 6% versus 47% versus 47% for SLD, and 18.8% versus 75% versus 6.2% for LLD (P=0.01). I-allele frequency was 0.29 for the shorter distance swimmers, and 0.59 for the 25 km group. These data are consistent with an association of ACE I allele with longer distance swimming, and the ACE D allele with swimming shorter distances. [ABSTRACT FROM AUTHOR]

Studies the statin therapy and the acute inflammatory response after coronary artery bypass grafting (CABG). Relations of baseline and postoperative plasma interleukin-6 to CABG; Myocardial protection; Effect of low-density lipoproteins on interleukin-6 ribonucleic acid expression.

Aims Postoperative cognitive dysfunction (POCD) is often experienced by cardiac surgery patients; however, it is not known if some groups of patients experience this more frequently or severely than others. The aim of this systematic review was to identify preoperative and postoperative predictors of cognitive dysfunction in adults following cardiac surgery. Methods and results Eight bibliographic databases were searched (January 2005 to March 2021) in relation to cardiac surgery and cognition. Studies including adult patients who had undergone open cardiac surgery and using a validated measurement of cognitive function were included. Full-text review for inclusion, quality assessment, and data extraction were undertaken independently by two authors. A total of 2870 papers were identified, of which 36 papers met the inclusion criteria and were included in the review. The majority were prospective observational studies [ n  = 28 (75.7%)]. In total, 61 independent predictors (45 preoperative and 16 postoperative) were identified as significant in at least one study; advancing age and education level appear important. Age has emerged as the most common predictor of cognitive outcome. Conclusion Although a number of predictors of POCD have been identified, they have inconsistently been reported as significantly affecting cognitive outcome. Consistent with previous research, our findings indicate that older patients and those with lower educational levels should be prioritized when developing and trialling interventions to improve cognitive function. These findings are less than surprising if we consider the methodological shortcomings of included studies. It is evident that further high-quality research exploring predictors of POCD is required. Registration This review was registered on Prospero, CRD42020167037 [ABSTRACT FROM AUTHOR]

Background: Atrial Fibrillation After Cardiac Surgery (AFACS) occurs in about one in three patients following Coronary Artery Bypass Grafting (CABG). It is associated with increased short- and long-term morbidity, mortality and costs. To reduce AFACS incidence, efforts are often made to maintain serum potassium in the high-normal range (≥ 4.5mEq/L). However, there is no evidence that this strategy is efficacious. Furthermore, the approach is costly, often unpleasant for patients, and risks causing harm. We describe the protocol of a planned randomized non-inferiority trial to investigate the impact of intervening to maintain serum potassium ≥ 3.6 mEq/L vs ≥ 4.5 mEq/L on incidence of new-onset AFACS after isolated elective CABG. Methods: Patients undergoing isolated CABG at sites in the UK and Germany will be recruited, randomized 1:1 and stratified by site to protocols maintaining serum potassium at either ≥ 3.6 mEq/L or ≥ 4.5 mEq/L. Participants will not be blind to treatment allocation. The primary endpoint is AFACS, defined as an episode of atrial fibrillation, flutter or tachycardia lasting ≥ 30 seconds until hour 120 after surgery, which is both clinically detected and electrocardiographically confirmed. Assuming a 35% incidence of AFACS in the 'tight control group', and allowing for a 10% loss to follow-up, 1684 participants are required to provide 90% certainty that the upper limit of a one-sided 97.5% confidence interval (CI) will exclude a > 10% difference in favour of tight potassium control. Secondary endpoints include mortality, use of hospital resources and incidence of dysrhythmias not meeting the primary endpoint (detected using continuous heart rhythm monitoring). Discussion: The Tight K Trial will assess whether a protocol to maintain serum potassium ≥ 3.6 mEq/L is non inferior to maintaining serum potassium ≥ 4.5 mEq/L in preventing new-onset AFACS after isolated CABG. Trial registration: ClinicalTrials.gov Identifier: NCT04053816. Registered on 13 August 2019. Last update 7 January 2021. [ABSTRACT FROM AUTHOR]

Aims Women are underrepresented in cardiovascular trials. We sought to explore the proportional representation of women in contemporary cardiovascular research and the factors (barriers and enablers) that affect their participation in cardiovascular studies. Methods and results Multiple electronic databases were searched between January 2011 and September 2021 to identify papers that defined underrepresentation of women in cardiovascular research and/or reported sex-based differences in participating in cardiovascular research and/or barriers for women to participate in cardiovascular research. Data extraction was undertaken independently by two authors using a standardised data collection form. Results were summarised using descriptive statistics and narrative synthesis as appropriate. From 548 identified papers, 10 papers were included. Of those, four were conducted prospectively and six were retrospective studies. Five of the retrospective studies involved secondary analysis of trial data including over 780 trials in over 1.1 million participants. Overall, women were reported to be underrepresented in heart failure, coronary disease, myocardial infarction, and arrhythmia trials, compared to men. Barriers to participation included lack of information and understanding of the research, trial-related procedures, the perceived health status of the participant, and patient-specific factors including travel, childcare availability, and cost. A significantly higher likelihood of research participation was reported by women following a patient educational intervention. Conclusion This review has highlighted the underrepresentation of women in a range of cardiovascular trials. Several barriers to women's participation in cardiovascular studies were identified. Researchers could mitigate against these in future trial planning and delivery to increase women's participation in cardiovascular research. Registration The protocol was published on the public Open Science Framework platform on 13th August 2021 (no registration reference provided) and can be accessed at https://osf.io/ny4fd/. [ABSTRACT FROM AUTHOR]

Fungi of the genus Alternaria are ubiquitous plant pathogens and saprophytes which are able to grow under varying temperature and moisture conditions as well as on a large range of substrates. A spectrum of structurally diverse secondary metabolites with toxic potential has been identified, but occurrence and relative proportion of the different metabolites in complex mixtures depend on strain, substrate, and growth conditions. This review compiles the available knowledge on hazard identification and characterization of Alternaria toxins. Alternariol (AOH), its monomethylether AME and the perylene quinones altertoxin I (ATX-I), ATX-II, ATX-III, alterperylenol (ALP), and stemphyltoxin III (STTX-III) showed in vitro genotoxic and mutagenic properties. Of all identified Alternaria toxins, the epoxide-bearing analogs ATX-II, ATX-III, and STTX-III show the highest cytotoxic, genotoxic, and mutagenic potential in vitro. Under hormone-sensitive conditions, AOH and AME act as moderate xenoestrogens, but in silico modeling predicts further Alternaria toxins as potential estrogenic factors. Recent studies indicate also an immunosuppressive role of AOH and ATX-II; however, no data are available for the majority of Alternaria toxins. Overall, hazard characterization of Alternaria toxins focused, so far, primarily on the commercially available dibenzo-α-pyrones AOH and AME and tenuazonic acid (TeA). Limited data sets are available for altersetin (ALS), altenuene (ALT), and tentoxin (TEN). The occurrence and toxicological relevance of perylene quinone-based Alternaria toxins still remain to be fully elucidated. We identified data gaps on hazard identification and characterization crucial to improve risk assessment of Alternaria mycotoxins for consumers and occupationally exposed workers. [ABSTRACT FROM AUTHOR]

Introduction: Designated cross-specialty shock teams have been proposed as a mechanism to manage the complexity of decision-making and facilitate collaborative, patient-centred care-planning in cardiogenic shock. Observational data support the notion that shock protocols and teams may improve survival, but there is an absence of data interrogating how clinicians engage with and value the shock team paradigm. This study sought to explore clinician perceptions of the value of the shock call system on decision making and the management of CGS.Materials& Methods: A descriptive qualitative approach was used. A focus group, semi-structured interview was conducted with twelve cross-specialty members of a shock team at a single tertiary cardiac centre in the UK. The focus group was audio-recorded, transcribed, and thematically analysed to capture and describe the clinicians' experience and perceptions of shock team discussions.Results: Eight cardiac intensivists, two heart failure cardiologists, one cardiothoracic surgeon and one interventional cardiologist participated in the focus group. Four key themes were identified from the discussions: supportive decision making; team communication; governance and learning; and future directions.Conclusion: This study supports the notion that cross-specialty, real-time patient discussion may provide added value beyond protocolised decision making and account for the complexities of managing patients in a field where definitive, high-quality evidence to guide practice is currently limited. [ABSTRACT FROM AUTHOR]

Aims: A cardiac surgery international nursing and allied professional research network titled CONNECT was created to strengthen collaborative cardiac surgery research through shared initiatives including supervision, mentorship, workplace exchange programs, and multi-site clinical research. As with any new initiative, there is a need to build brand awareness to enhance user familiarity, grow membership, and promote various opportunities offered. Social media has been used across various surgical disciplines; however, their effectiveness in promoting scholarly and academic-based initiatives has not been examined. The aim of this scoping review was to examine the different types of social media platforms and strategies used to promote cardiac research initiatives for CONNECT. Methods and results: A scoping review was undertaken in which a comprehensive and thorough review of the literature was performed. Fifteen articles were included in the review. Twitter appeared to be the most common form of social media used to promote cardiac initiatives, with daily posts being the most frequent type of engagement. Frequency of views, number of impressions and engagement, link clicks, and content analysis were the most common types of evaluation metrics that were identified. Conclusion: Findings from this review will inform the design and evaluation of a targeted Twitter campaign aimed at increasing brand awareness of CONNECT, which will include the use of @CONNECTcardiac Twitter handle, hashtags, and CONNECT-driven journal clubs. In addition, the use of Twitter to disseminate information and brand initiatives related to CONNECT will be evaluated using the Twitter Analytics function. Registration: Open Science Framework: osf.io/q54es Graphical Abstract [ABSTRACT FROM AUTHOR]