Sociology of health & illnessEliza Brown, Stefan Timmermans
Notions of good or bad luck sit uncomfortably in contemporary medical practice defined by efforts to control life through biomedical knowledge and skilled expertise. Yet, talk about luck is common in healthcare to explain medical courses of action. Framing medical results as fortunate or unfortunate bridges the gap between predicted probabilities and variation in individual cases without undermining scientific neutrality. Luck mediates between the rational ideal of biomedical determinism that does not easily account for variable health outcomes and the magical invocation of faith or fate that denotes a moral judgement. Drawing from ethnographic studies of heart transplantation and fertility medicine, we find that luck is employed as an anticipatory frame to guide decision-making in medicine and as a retroactive frame to justify unlikely outcomes. Invoking luck primes patients for the possibility of a favourable outcome and inserts a positive bias in medical care. The analysis underlines how luck frames in healthcare can shift attention away from structural reasons for disparate outcomes, attempt to absolve healthcare providers of blame from medical errors and promote continuing treatment. These findings indicate that focusing on when healthcare providers and patients invoke luck reveals the scope and limits of medical power and control.
Pain practice : the official journal of World Institute of PainYonghyun Yoon, King Hei Stanley Lam, Daniel Chiung-Jui Su, Teinny Suryadi, Anwar Suhaimi
BACKGROUND: Chest tube thoracostomy may cause iatrogenic nerve injury, resulting in persistent pain and functional impairment. Long thoracic nerve (LTN) palsy after chest tube placement has been described, but concurrent involvement of the LTN and the lateral cutaneous branch of an intercostal nerve (LCIN) appears to be rarely reported. We describe a patient with persistent post-thoracostomy chest wall pain and scapular winging in whom musculoskeletal ultrasonography identified entrapment of both nerves. CASE PRESENTATION: A 43-year-old man presented with severe left shoulder and chest wall pain 6 months after chest tube placement for traumatic hemopneumothorax. Examination demonstrated focal tenderness, dysesthesia, and mechanical allodynia at the chest tube scar, along with medial/inferior scapular winging during serratus anterior provocative testing. Shoulder range of motion was full on examination; however, forward flexion beyond 15° markedly aggravated pain, resulting in pain-related reluctance to move the shoulder. Manual muscle testing was 4+/5 before treatment because pain limited force generation. Musculoskeletal ultrasound demonstrated focal abnormality of the LTN where it pierced the axillary fascia over the sixth rib, with loss of fascicular definition and reduced glide, and tethering/thickening of the LCIN within scar tissue at the prior tube insertion site. Symptom reproduction with sonopalpation supported the clinical relevance of both findings. INTERVENTION AND RESULTS: Ultrasound-guided hydrodissection using 5% dextrose in water was performed around both nerves. A total of approximately 40 mL of 5% dextrose in water was used, with 20 mL administered per nerve. Immediately after the first procedure, pain improved from NRS 9/10 to 2/10, with marked reduction in pain during shoulder movement, including forward flexion. The patient subsequently underwent 5 treatment sessions at 2-week intervals over 10 weeks. During follow-up, manual muscle testing improved to 5/5 without pain, scapular winging was no longer evident on provocative testing, and the Shoulder Pain and Disability Index improved from pain/disability scores of 25/15 to 6/4. At the sixth follow-up visit, pain and function were satisfactory, and the patient elected continued monitoring without further intervention. At 1-year follow-up, treatment efficacy remained sustained without recurrence. CONCLUSION: In patients with persistent shoulder or chest wall pain after chest tube thoracostomy, iatrogenic peripheral nerve entrapment should be considered. This case highlights the value of a focused neuromuscular examination and musculoskeletal ultrasound for identifying concurrent motor and sensory nerve involvement and suggests that ultrasound-guided hydrodissection may be a useful minimally invasive treatment. Because electrodiagnostic studies were not performed, the findings are most consistent with entrapment/neurapraxia with dynamic tethering rather than electrodiagnostically proven axonal palsy.
Acta anaesthesiologica ScandinavicaJulie T Holm, Sebastian C Wiberg, Lars Grønlykke, Sarah E Busch, Peter Hasse Møller-Sørensen, Christian Hassager, Theis S Itenov
INTRODUCTION: Myocardial injury is a significant contributor to 30-day mortality after cardiac surgery with cardiopulmonary bypass. We aimed to investigate the association between mean arterial pressure, norepinephrine use during the aorta cross-clamp period, and aorta cross-clamp duration with myocardial injury during cardiopulmonary bypass-assisted open-heart surgery. METHOD: We identified all adults (≥ 18 years) undergoing coronary artery bypass grafting on cardiopulmonary bypass at Rigshospitalet, Copenhagen, between January 1st 2018 and December 31st 2019. The primary outcome was the change from baseline in creatine kinase myocardial band during the first 18 postoperative hours. Exposures included mean arterial pressure, norepinephrine use during the aorta cross-clamp period, and aorta cross-clamp duration. Associations were investigated using linear mixed-effect models. RESULTS: A total of 1443 patients were included in the analysis. Patients treated with norepinephrine during the aortic cross-clamp period had 19% (95% CI: 9.0%-29%; p < 0.001) higher creatine kinase myocardial band postoperatively compared with those not treated with norepinephrine. Higher mean arterial pressure was not significantly associated with creatine kinase myocardial band (3.0%, 95% CI: -2.0% to 9%; p = 0.20). Patients treated with norepinephrine with a mean arterial pressure above the median (39 mmHg) had similar creatine kinase myocardial band levels compared to patients not treated with norepinephrine with a mean arterial pressure below the median, with a difference of 2% (95% CI: -0.18% to 0.22%, p = 0.80). Creatine kinase myocardial band increased by 12% (95% CI: 10%-14%; p < 0.001) for each 15-min increase in aortic cross-clamp duration. CONCLUSION: This retrospective observational study suggested a possible link between norepinephrine use and myocardial injury during cardiopulmonary bypass-assisted open-heart surgery, while mean arterial pressure appeared to have no impact. Further randomized controlled trials are necessary. EDITORIAL COMMENT: In this single center retrospective cohort analysis, intraoperative cardiac surgery management factors were analyzed along with postoperative cardiac injury marker levels. Associations for aortic cross-clamp time, noradrenaline use during this, and mean arterial pressures are presented for post-op creatine kinase MB levels.
Nursing in critical careFranziska Wefer, Lars Krüger, Stella Calo, Ralph Möhler, Martin Nikolaus Dichter, Andrea Mühring, Jan Gummert, Sascha Köpke
BACKGROUND: Hospitalised patients with advanced chronic heart failure (CHF) waiting for transplantation may experience increased thirst due to their critical illness and therapy-related requirements. The perspective of patients and nurses is important for developing a nurse-based counselling intervention to reduce thirst. AIMS: To identify patients' and nurses' experiences and perceptions of thirst, as well as their information needs and preferences on information dissemination. STUDY DESIGN: This convergent mixed methods study used semi-structured interviews with patients, focus groups and a survey with nurses in Germany. We analysed the qualitative data using content analysis and the quantitative data descriptively. We compared the results of both methodological approaches and summarized the data as meta-inferences. RESULTS & FINDINGS: We conducted 10 interviews with patients on intensive care units, intermediate care units and general wards during their waiting time for transplantation, two focus groups with, respectively, five nurses and a survey with 59 nurses caring for these patients. Analyses resulted in five common categories: experiences of thirst, factors that influence thirst, assessment of thirst, dealing with thirst and information about thirst. Patients' experiences with thirst differ markedly, ranging from mild to severe thirst, and they use various strategies to deal with thirst. Nurses consider thirst relevant for patients and nursing care. Strategies used in practice for assessment of thirst are very heterogeneous. In the survey, less than half of the nurses claimed to regularly assess patients' thirst. Nurses and patients wish to receive individual information and counselling. CONCLUSIONS: Thirst in hospitalised patients with advanced CHF waiting for transplantation can be severe and is experienced differently. Standardised procedures for assessing and managing thirst on the ward seem essential to address patients' needs and preferences. RELEVANCE TO CLINICAL PRACTICE: Patients and nurses express a need for professional counselling on managing thirst in clinical practice.
Journal of robotic surgeryXuefeng Hu, Usha Seshadri-Kreaden, Ana Yankovsky, Danni Xiao, Haoran Zhan, Neera M Patel, Yifan Xu, Yu-Hsiang Kao, Ben Forrest, Ziting Wu, Beini Lyu
The use of robot-assisted surgery (RAS) has increased markedly in China, but comparative evidence on its perioperative performance in cancer care is dispersed across specialties and study designs. This review synthesized Chinese evidence to examine the safety and effectiveness of da Vinci robot-assisted surgery (dV-RAS) relative to laparoscopic/video-assisted thoracoscopic surgery (LAP/VATS) and open surgery across seven oncologic procedures. We systematically reviewed comparative studies published from 2010 to 2024 and pooled estimates for dV-RAS versus LAP/VATS or open surgery. Prespecified perioperative outcomes were conversion to open surgery, operative time, estimated blood loss, blood transfusion, hospital length of stay, postoperative complications, readmission, reoperation, and 30-day mortality. The review included 116 studies. Relative to LAP/VATS, dV-RAS was associated with lower odds of conversion to open surgery (odds ratio [OR] 0.26; 95% confidence interval [CI] 0.21-0.33; p < 0.01), less blood loss (mean difference [MD] - 32.48 mL; 95% CI - 40.86 to - 24.11; p < 0.01), lower odds of transfusion (OR 0.61; 95% CI 0.51-0.73; p < 0.01), a shorter hospital stay (MD - 1.06 days; 95% CI - 1.30 to - 0.82; p < 0.01), fewer 30-day postoperative complications (OR 0.67; 95% CI 0.61-0.73; p < 0.01), and fewer reoperations (OR 0.62; 95% CI 0.40-0.96; p = 0.03). Comparisons with open surgery likewise favored dV-RAS for blood loss, transfusion, length of stay, and postoperative complications. Operative time, readmission, and 30-day mortality did not differ significantly between approaches. Across seven oncologic procedures, pooled evidence from China indicated that dV-RAS was associated with better outcomes on several perioperative measures than LAP/VATS or open surgery. Because between-study heterogeneity was substantial and most included studies were retrospective, the findings should be interpreted cautiously and confirmed in higher-quality prospective research.
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic SurgeryRuggero De Paulis, Giulio Folino, Alain Berrebi, Filip P A Casselman, Rui J Cerqueira, Alessandro Della Corte, Laurent De Kerchove, Yves d'Udekem, Alberto Fort…
Aortic valve repair is a complex and evolving field that requires multidisciplinary teamwork among heart specialists to diagnose and treat various causes and mechanisms of aortic regurgitation and proximal thoracic aortic aneurysms across all age groups. From a surgical standpoint, aortic valve repair includes all procedures aimed at restoring or maintaining native valve function. This European Association for Cardio-Thoracic Surgery (EACTS) Expert Consensus Document critically evaluates the current evidence on the common causes and mechanisms of aortic regurgitation, the use of echocardiographic parameters in patient selection, intraoperative assessment, and prognostic evaluation as well as the surgical techniques in practice. It outlines fundamental surgical principles shared across different repair methods and provides consensus statements to guide clinical practice. These statements are intended for a broad audience, including paediatric and adult cardiologists, echocardiographers, cardiovascular imaging specialists, and cardiac surgeons. Where high-quality evidence is unavailable, the guidance relies on the collective experience and expert judgement of the multidisciplinary author team. This document presents the official stance of the EACTS and aims to promote standardized, evidence-based decision-making in the management of patients undergoing aortic valve repair.
Interdisciplinary cardiovascular and thoracic surgeryThomas Syburra, Edward D Nicol, Carlos A Mestres, Milos Matkovic, Joanna d'Arcy, Denis Bron, Filip Casselman, Martin Czerny, Stephen Fremes, Norbert Guettler, …
Civil aviation medicine and cardiothoracic surgery intersect at a point where individual clinical outcomes and public safety are tightly coupled. Professional aircrew and other safety-critical aviation personnel must meet legally defined medical standards that are designed around an engineering approach to risk, including a low annual tolerance for sudden incapacitation, whereas passengers and cabin crew are exposed to the physiological constraints of the flight environment (hypobaric hypoxia, gas expansion, limited access to medical care, immobility, and circadian rhythm disruption). Yet, the evidence base guiding fitness-to-fly decisions after cardiothoracic procedures, treatment of aortic disease, and contemporary transcatheter interventions remains sparse and unevenly distributed across procedures, licensing classes, and operational contexts. This European Association of Cardio-Thoracic Surgery Expert Consensus Document appraises the available literature and synthesizes multidisciplinary expert knowledge to provide pragmatic, safety-oriented guidance for aeromedical examiners, treating clinicians, regulators, employers, and affected individuals. Focusing on civil aviation, it addresses return-to-duty considerations for professional aircrew and postoperative air-travel decisions for passengers. Key clinical and occupational determinants include procedure choice and durability, residual ischaemia or haemodynamic burden, arrhythmia risk, anticoagulation and device-related considerations, rehabilitation and surveillance testing, and, where appropriate, the role of operational restrictions such as multicrew limitations. Finally, it identifies key knowledge gaps and research priorities to support more consistent, evidence-based decision-making in this high-stakes setting.
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic SurgeryWouter Oosterlinck, Meindert Palmen, Monica Gianoli, Milan Milojevic, Jan Bekaert, Friedhelm Beyersdorf, Filip P A Casselman, Karlien Degezelle, Volkmar Falk, …
Robotic cardiac surgery is entering a renewed phase of adoption, supported by growing clinical experience, evolving robotic platforms, and rising demand for less invasive procedures and faster recovery. However, implementation remains technically demanding and resource-intensive and can expose patients to avoidable harm when initiated without a structured training programme, clear technical standards, and rigorous outcome monitoring. This expert consensus document summarizes the current state of robotic cardiac surgery and defines requirements for the safe, effective, and sustainable development of robotic cardiac programmes. It addresses the current regulatory environment for surgical robots and accessories and proposes minimum requirements for hardware, software, and instruments for reconstructive intracardiac and coronary cardiac procedures. Furthermore, it outlines prerequisites for starting and developing training centres, including surgeon experience, multidisciplinary team composition, patient selection, and institutional infrastructure and volume considerations. A stepwise, competency-based training pathway is presented that integrates video and live case observation, virtual and simulation-based skills acquisition, wet/dry laboratory training, and proctored clinical implementation, ideally supported by dual-console systems. The document emphasises the need for transparent documentation and outcome benchmarking via a society-driven database to support quality assurance, learning-curve oversight, and continuous improvement. Finally, it highlights priorities for further research, including harmonized reporting standards, long-term and procedure-specific outcome evaluation, and prospective studies assessing training models, cost-effectiveness, and the incremental value of emerging technologies.
Immunologic researchJosé Roberto Mendes Pegler, Débora Linhares Rodrigues, Renata de Almeida Bordim, Patricia Palmeira, Andréia Rangel-Santos, Isabela de Jesus Silva Avelar, Ana C…
Early thymectomy during congenital heart disease repair may impair thymic output, but long-term effects across age groups remain incompletely defined. We evaluated T-cell receptor excision circles (TRECs) and a comprehensive panel of lymphocyte subsets in 20 adults (mean age, 29.6 years) and 16 children (mean age, 10.7 years) who underwent thymectomy within the first year of life, and in age- and sex-matched controls. TRECs were lower in patients than controls in adults (34 ± 25 vs. 79 ± 45 copies/μL; FDR-adjusted p = 0.001) and children (9 [7-15] vs. 95 [65-160] copies/μL; FDR-adjusted p < 0.0001). Total lymphocyte and T-cell counts were reduced in both age groups, mainly due to lower naïve CD4⁺ and CD8⁺ T cells, including recent thymic emigrants. Most non-naïve subsets did not differ significantly from controls. Regulatory T-cell (Treg) alterations differed by age: children showed broad reductions, whereas adults showed selective naïve Treg reduction. Early thymectomy is associated with persistent thymic output impairment, including in adults approximately three decades after surgery, and with age-specific Treg alterations.
Science advancesQiqi Pan, Wenke Duan, Jingjing Luo, Lei Wang, Shijie Guo, Yongfei Feng, Hongbo Wang
Lateral force blind spots frequently trigger airway injuries during robotic bronchoscopy. Traditional sensing approaches lack fine spatial resolution, and single-segment robots suffer poor posture adjustment flexibility, worsening unmonitored tissue contact. We integrate a snake-scale-inspired 64-channel gradient piezoelectric film with a dual-segment manipulator to resolve lateral blind spots for secure bronchial navigation. The conformally wrapped sensor delivers fast (<10 ms), precise force detection (R2 > 0.98, RMSE < 0.145 N, CV < 2%) and filters bending pseudo-forces. The dual-segment design enables coordinated proximal-distal motion to avoid overcontact in tortuous lumens. Phantom and ex vivo porcine lung tests confirm real-time force localization, 5.0 N safety alarms, and autonomous tuning to keep contact forces below 3.0 N. This synergistic robot-sensor design supplies a translatable safety control strategy for flexible surgical manipulators.
Clinical nurse specialist CNSMichael Gnidovec, Deb L Lindell
PURPOSE/OBJECTIVES: The project aimed to improve the safety of hospitalized tracheostomy and laryngectomy adults by reducing the time to initial respiratory therapist assessment and the delivery of emergency equipment to the bedside. DESCRIPTION: Tracheostomy and laryngectomy patients are classified as a low-volume, high-risk patient population. The specialized care and equipment needed for them are essential, especially in an acute care setting like a hospital. The ability to ensure safety equipment compliance at the time of admission is a challenge as it relies heavily on communication, which can be subject to human error. Three months of retrospective data were analyzed, which led the team to identify a gap in the notification process. The project team created an automated pager notification of new patients needing assessment and delivery of emergency equipment, triggered by an EHR notification when the patient's status changed to admitted. OUTCOME: A Kruskal-Wallis test compared time to assessment between the 2 groups and established that the difference was not statistically significant (P=0.121). However, the lower mean and median times to assessment in the postintervention group are clinically significant for this population. CONCLUSIONS: Automated notifications were effective in reducing delays in care and delivery of emergency equipment for this vulnerable population. .
Journal of medical Internet researchMingming Deng, Weidong Xu, Fei Tang, Hong Chen, Zhen Yang, Feng Wang, Nan Zhang, Haihong Wu, Jia Li, Ziwen Zheng, Sinan Wu, Gang Hou
BACKGROUND: Risk disclosure before bronchoscopy should provide sufficient information for informed consent, but detailed text-based risk disclosure may increase procedural anxiety. Patient-specific visualization with a digital twin-based bronchoscopy simulator may help patients understand bronchoscopy and its risks in a more individualized manner. OBJECTIVE: This study evaluated whether digital twin-assisted risk disclosure reduces prebronchoscopy anxiety and improves postbronchoscopy satisfaction compared with conventional risk disclosure in adults scheduled for elective bronchoscopy. METHODS: We conducted a multicenter, parallel-group randomized controlled trial. Adults aged 18 years or older scheduled for elective bronchoscopy under local anesthesia were included. Participants were randomized to either a digital-twin informed-consent group, which received standard written information plus a physician-led oral explanation supported by a patient-specific simulator visualization, or a conventional informed-consent group, which received the same written information plus a standard physician-led oral explanation without simulator visualization. Owing to the nature of the intervention, participants and physicians were not blinded. The primary outcome was the change in self-reported anxiety after risk disclosure, measured using the visual analog scale (VAS) and the modified Amsterdam Preoperative Anxiety and Information Scale (APAIS). Linear mixed models with a group-by-time interaction were used for the main analysis. The secondary outcome was postbronchoscopy satisfaction. RESULTS: Of 150 patients assessed for eligibility, 122 were randomized and analyzed, with 61 participants in each group. Compared with conventional risk disclosure, digital twin-assisted disclosure produced greater reductions in anxiety on the VAS (group by time β=-15.89, SE 3.08, 95% CI -21.99 to -9.78; P<.001) and APAIS total anxiety score (β=-6.77, SE 0.98, 95% CI -8.71 to -4.83; P<.001). Similar effects were observed for APAIS procedure-related anxiety (β=-4.25, 95% CI -5.47 to -3.02; P<.001) and APAIS outcome-related anxiety (β=-2.52, 95% CI -3.46 to -1.59; P<.001). Clinically meaningful improvement occurred more often in the digital-twin group for VAS (30/61, 49.2% vs 4/61, 6.6%) and APAIS (33/61, 54.1% vs 6/61, 9.8%; both P<.001). Satisfaction was higher in the digital-twin group (mean 16.89, SD 2.08 vs mean 14.38, SD 1.89; P<.001). All participants completed bronchoscopy without complications or adverse conditions. CONCLUSIONS: Patient-specific digital twin-visualization during physician-led risk disclosure reduced short-term self-reported anxiety and modestly improved satisfaction. The innovation lies in using each patient's computed tomography-derived airway and lesion anatomy during consent rather than standardized text, audiovisual content, or graphic narratives evaluated previously. This multicenter trial extends digital-twin technology from bronchoscopy training to individualized risk communication. In clinical practice, the approach could supplement physician-led consent in units with computed tomography and simulator infrastructure; however, time-matched studies should establish objective benefits, workflow burden, cost-effectiveness, accessibility, and applicability to highly anxious or resource-limited populations before wider adoption.
BMJ case reportsAndres Fontaine-Nicola, Emiliano Gabriel Manueli Laos, Mario A Masrur, Kevin L Kovitz, Odile David, Khaled Abdelhady
This case report describes a rare presentation of pulmonary melanoma of unknown primary managed through a same-day robotic diagnostic and therapeutic approach. A man in his 70s with an incidentally detected lingular pulmonary nodule suspicious for non-small cell lung cancer underwent robotic navigation bronchoscopy for biopsy and dye marking, immediately followed by robotic-assisted thoracic surgery. Intraoperative frozen section revealed a malignant spindle cell neoplasm, prompting definitive surgical resection during the same anaesthetic event. Final histopathology and molecular analysis confirmed melanoma, with no identifiable cutaneous, mucosal or ocular primary. The patient subsequently received adjuvant immunotherapy and remains disease-free at 24 months. This case highlights the diagnostic challenge of pulmonary melanoma mimicking lung carcinoma and demonstrates how integration of robotic bronchoscopy and robotic surgery can enable rapid diagnosis, definitive management and streamlined care within a single operative session.
BMJ openRebeka Jenkins, Gillian Hardman, Karen Booth, John Dark, Andrew Fisher, Catherine Exley
OBJECTIVES: This study explores decision-making in organ transplantation. The number of patients waiting for a solid organ transplant continues to rise despite efforts to increase the available pool of donor organs. This has focused attention on maximising the number of organs offered that are subsequently transplanted, a process termed organ utilisation. There is a paucity of work exploring how clinicians decide to decline or accept offers of donor organs. This study aims to better understand the factors that influence organ utilisation decision-making in cardiac and thoracic transplantation through qualitative methods. DESIGN: Semi-structured qualitative interviews undertaken online over a 5-month period. Data collection and analysis occurred simultaneously. Transcripts were inductively analysed to generate themes. SETTING: Clinicians representing all six adult UK cardiothoracic transplant centres. PARTICIPANTS: Consultant cardiothoracic transplantation surgeons (n=9) and cardiothoracic transplant coordinators (n=10). RESULTS: 19 interviews were undertaken. The following themes pertinent to utilisation decision-making were identified: anticipation of outcomes; data; motivation; out-of-hours; micro-culture and experiential learning. CONCLUSIONS: This study is the first to explore the process of organ utilisation decision-making from a clinician's perspective through interviews. This documents an important and nuanced understanding of the interrelated factors involved in utilisation decision-making in practice. By providing evidence for the human inconsistencies in utilisation decision-making, this work may inform a more considered approach to strategies to improve utilisation rates.
Deutsche medizinische Wochenschrift (1946)Isabel Horn, Tanja Rudolph
Aortic valve diseases are among the most common structural heart diseases in adults. Aortic stenosis (AS), in particular, poses a growing challenge due to demographic trends, as it continues to be underdiagnosed.The current 2025 ESC/EACTS guidelines mark a paradigm shift: for the first time, early intervention is recommended for selected asymptomatic patients. At the same time, various AI tools support early patient screening.Also new, with a Class IIb recommendation, is that TAVI may be considered for patients with a bicuspid aortic valve and increased surgical risk, provided the anatomy is suitable.In addition to that the age limit for TAVI implantation has been lowered to 70 years for patients with suitable anatomy and a tricuspid aortic valve (Class IA recommendation). Another point is that concerning the choice between SAVR and TAVI the importance of the interdisciplinary heart team, taking into account anatomy, comorbidities, and lifestyle considerations was highlighted.Patients with severe aortic valve stenosis should be referred by their primary care cardiologist to a cardiac center so that an interdisciplinary cardiac team can determine the best possible treatment option for the patient.Concerning screening of patients with valvular heart disease artificial intelligence is playing an increasingly important role. Tools such as the digital stethoscope and ECG-based screening help improve patient screening.
Deutsche medizinische Wochenschrift (1946)Ander Arteagoitia, Philipp Lurz, Marc Adrian Rogmann
Mitral valve disease ranks among the most frequent valvular conditions and carries significant morbidity and mortality if left untreated. This review addresses anatomy, the Carpentier classification, and echocardiographic severity grading, as well as current management of primary and secondary mitral regurgitation (MR) and mitral stenosis. Transcatheter therapies, including edge-to-edge repair and transcatheter mitral valve replacement, receive particular attention and are discussed in the context of four clinical cases from a specialized valve center.
Deutsche medizinische Wochenschrift (1946)Philipp von Stein, Stephan Baldus
Tricuspid valve disease encompasses a spectrum of conditions, among which tricuspid regurgitation is the most prevalent and clinically significant. Affected patients are typically elderly and present with systemic congestion, impaired renal and hepatic function, and reduced quality of life. Echocardiography enables mechanistic classification, severity grading, and assessment of right ventricular function. While medical therapy remains foundational, transcatheter interventions - including edge-to-edge repair and valve replacement - have emerged as options for high-risk patients. Randomized trials demonstrate improvements in symptoms and quality of life, with emerging evidence for reductions in heart failure hospitalizations. This article provides a practice-oriented overview of diagnosis, management, and referral pathways for tricuspid valve disease, including rarer entities such as tricuspid stenosis, endocarditis, and carcinoid heart disease.
Journal of robotic surgeryChengcheng Cai, Tong Ren, Zhikang Ma, Kailun Dong, Baoyue Lu, Wenze Sun, Jianchang Zhao, Jianmin Li, Rong Wang, Lizhi Pan
Conventional robotic cardiac approaches generally require multiple intercostal access sites to establish instrument triangulation. This study presents an in-house-developed single-port robotic platform designed around cardiac manipulation requirements and evaluates its initial task-specific feasibility in one pig. The system integrates a common entry guide, three-dimensional endoscopic visualization, articulated instruments, and master-slave teleoperation. Robot-assisted internal mammary artery (IMA) dissection was performed on the beating heart through retractor-assisted intercostal access. Mitral annular suture placement was performed after planned terminal euthanasia, incision enlargement, and manual atrial exposure maintained with suspension sutures. Cardiopulmonary bypass was not used. A 115-mm IMA segment was skeletonized robotically during a 49-min dissection interval within an 87-min IMA phase, followed by manual clipping and division. No additional robotic port was required, and no macroscopic IMA injury or major bleeding was observed during dissection. Mitral annular suture placement was completed at nine positions in 46 min using coordinated bimanual manipulation. These observations provide preliminary evidence that intrathoracic deployment and distal articulation can support the selected cardiac tasks under the reported conditions. The findings provide a basis for technical refinement and further preclinical evaluation but do not establish reproducibility, procedural safety, or the feasibility of a complete single-port mitral valve procedure.
Journal of robotic surgeryFrancina Valezka Bolaños-Morales, Jesús Carrranza-Zarmina, Edgar Castro-Santamaría, Carmen Margarita Hernández, Edtih Paramo, Mario Casas, Zeyda Juárez, Ricard…
Robotic-assisted thoracic surgery (RATS) has emerged as an important advancement in minimally invasive thoracic surgery; however, concerns regarding its economic impact continue to limit its broad adoption. We evaluated the early clinical outcomes and economic performance of a newly established robotic thoracic surgery programme in a tertiary referral centre in Mexico. A retrospective observational study was conducted, including consecutive patients undergoing RATS between October 2023 and June 2024. Clinical outcomes of the robotic cohort were analysed descriptively. Economic comparisons with conventional thoracic surgery were performed using institutional administrative costing data. A total of 116 patients underwent RATS. Median postoperative hospital stay was 5 (2-10) days, with a 90-day mortality of 1.7%. Economic performance differed according to procedure. Mediastinal tumour resection demonstrated lower overall institutional costs than conventional surgery, representing a dominant economic strategy. Thymectomy and bronchoplasty achieved favourable cost-effectiveness profiles below the two-times gross domestic product per capita willingness-to-pay threshold, whereas bullectomy remained cost-effective only under the three-times threshold. The implementation of a robotic thoracic surgery programme within a public healthcare institution was clinically feasible and demonstrated favourable economic performance in selected thoracic procedures. The economic sustainability of robotic thoracic surgery appears to be procedure-specific and may be facilitated by innovative implementation strategies and appropriate case selection.
Open heartOzan M Demir, Azeem Latib, Bernard Prendergast
The natural history of symptomatic severe aortic stenosis (AS) heralds a poor prognosis-a paradigm that rightly drives valve intervention. A widely voiced corollary holds that once patients exceed their nation's average life expectancy, aortic valve replacement offers no prognostic benefit. We argue that this corollary is statistically incoherent and potentially clinically harmful. Life expectancy at birth is a period average across a whole cohort, weighted by deaths at younger ages; it is not a ceiling on individual survival. Expectancy is conditional on survival already achieved: the longer a person has lived, the older they are expected to be at death. A man of 90 in England and Wales still has a mean of 3.9 years ahead of him, and an average 82-year-old will outlive an average 72-year-old. The patient who has 'beaten the average' has, by surviving, demonstrated membership of a longer-lived stratum-precisely the group with most to gain from a durable valve. The hazard in AS is cardiac, not chronological: it tracks extravalvular cardiac damage, frailty and competing illness rather than the calendar, and stage, not age, discriminates outcome after valve replacement. Futility is real-advanced cardiac damage, established frailty and prognosis-dominating comorbidity do foreclose benefit-but age is an inaccurate proxy for it. Drawing on natural history and clinical trial data, including cardiac damage staging, national life tables and the deprivation gradient, we propose replacing age-based nihilism with conditional, comorbidity-adjusted prognostication, with the expected gain estimated, documented and stated explicitly as part of consent and shared decision-making.
Journal of robotic surgeryAaron Guo, Jad Elharake, Chandler Lowe, Mahmoud Abdel-Rasoul, Marissa Guo, Shi-Hao Lee, Mallory Shields, Daniel Oh, Ioana Baiu, Peter J Kneuertz, Robert E Merr…
Trainee autonomy in robotic-assisted thoracic surgery is critical for growth but difficult to quantify. Robotic platforms can log intraoperative kinematic and event data that can be transformed into metrics known as objective performance indicators (OPIs). This study sought to use OPIs obtained during robotic-assisted anatomic lung resections to assess trainee console autonomy at a high-volume robotic center. OPI data were obtained from 59 lobectomies and segmentectomies performed on a multi-port robotic platform between March 2022 and May 2023. Cases were divided into anatomic steps and annotated by a team of verified video reviewers. Console autonomy was assessed based on average path length (PL) of controllers and active time (AT) on the trainee console as a ratio compared to the overall PL and AT of the operation. Cases included 51 (86%) lobectomies and 8 (13%) segmentectomies. Average overall PL ratio was 0.15 (SD 0.17) and overall AT ratio was 0.23 (SD 0.23) for senior trainees. Autonomy was highest for inferior pulmonary ligament division (PL ratio = 0.39, AT ratio = 0.42) while lowest with pulmonary artery dissection (PL ratio = 0.10, AT ratio = 0.14). There was a significant association between AT and PL ratio with estimated blood loss (PL p = 0.036, AT p = 0.047). AT and PL ratios can provide objective surrogates of autonomy in thoracic surgery and can be stratified by individual case components. OPIs will offer valuable metrics for surgical education and assessment as national accrediting bodies shift graduation requirements towards case component proficiency over volume.
EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of CardiologyTuomas T Rissanen, Simon Eccleshall, Florian Krackhardt, Kris Bogaerts, Tanios Akiki, Carlo Briguori, Guillaume Cayla, Nick Cruden, Alexander W den Hartog, Phi…
BACKGROUND: Drug-eluting stents (DES) are the current mainstay of percutaneous coronary intervention (PCI) in high bleeding risk (HBR) patients. However, drug-coated balloons may be an alternative that reduces reliance on prolonged courses of antiplatelet therapy. AIMS: The SELUTION DeNovo trial randomised 3,323 PCI candidates 1:1 to treatment with either sirolimus-eluting balloons (SEBs) and provisional stenting or systematic DES implantation. We report on a prespecified subgroup of HBR patients. METHODS: A total of 522 enrolled patients met the Academic Research Consortium-HBR criteria. At 1 year, we assessed target vessel failure (TVF; a composite of cardiac death, target vessel myocardial infarction and clinically driven target vessel revascularisation), major bleeding (Bleeding Academic Research Consortium [BARC] 3-5) and net adverse clinical events (NACE; a composite of TVF and BARC 3-5 bleeding). Antithrombotic treatment was prescribed according to current guidelines and local practice. RESULTS: Altogether, 269 and 253 patients were identified as HBR in the SEB strategy and DES strategy arms, respectively. In the SEB arm, 17.1% of patients had bailout stenting. Overall, 67% of patients were discharged on oral anticoagulants. At 1 year, TVF occurred in 4.9% of the SEB arm vs 7.9% of the DES arm (absolute risk difference [RD] -3.05%, 95% confidence interval [CI]: -7.27 to 1.17). BARC 3-5 bleeding occurred in 2.3% vs 3.2% (absolute RD -0.91%, 95% CI: -3.71 to 1.89) and NACE in 6.8% vs 10.7% (absolute RD -3.94%, 95% CI: -8.80 to 0.92) in the SEB and DES arms, respectively. While the proportion of patients on dual antiplatelet therapy and single antiplatelet therapy did not differ significantly between the two groups during follow-up, all antiplatelet medication was stopped in 7.7% vs 2.5% at 30 days (p=0.005) and in 27.8% vs 14.9% of patients at 6 months (p<0.001) in the SEB and DES arms, respectively. CONCLUSIONS: Although this subset analysis is not powered for definitive conclusions, our data suggest that an SEB strategy with minimal stenting appears to be a safe and effective alternative to systematic DES implantation for HBR patients.
Although drug-coated balloons (DCBs) are increasingly used in acute coronary syndrome (ACS), evidence regarding mid-term clinical outcomes after DCB angioplasty remains limited. Real-world data evaluating whether intravascular ultrasound (IVUS)-guided lesion preparation is associated with improved outcomes compared with angiography-guided intervention are scarce, particularly in patients with complex coronary lesions. This study compares clinical outcomes associated with IVUS versus coronary angiography (CAG) guidance for DCB angioplasty in patients with ACS, focusing on major adverse cardiovascular events (MACE) and net adverse clinical events (NACE) within the prespecified 24-month observation window. This retrospective study included 229 patients with ACS treated with DCB angioplasty between October 2017 and June 2025. Patients were categorized into IVUS-guided (n = 122) and CAG-guided (n = 107) groups according to the imaging strategy used during the procedure. Inverse probability of treatment weighting (IPTW) was applied to adjust for baseline confounders. The primary endpoints were MACE and NACE occurring within the prespecified 24-month observation window after DCB angioplasty. Secondary outcomes included individual clinical events, procedural characteristics, length of stay, and biochemical parameters assessed at predefined follow-up time points. After IPTW adjustment, baseline characteristics were balanced between groups. Procedural parameters, including DCB diameter, number of DCBs deployed, and bailout stenting rate, were comparable (all P > .05). Within the prespecified 24-month observation window, MACE occurred less frequently in the IVUS group than in the CAG group (8.2% vs 17.8%; IPTW P = .038). Major bleeding was also lower in the IVUS group (1.6% vs 11.2%; IPTW P = .015), contributing to a lower incidence of NACE (9.8% vs 26.2%; IPTW P = .001). IVUS guidance was additionally associated with a shorter hospital stay (4.2 vs 5.8 days; P < .001), while biochemical parameters remained comparable during follow-up. In patients with ACS treated with DCB, IVUS‑guided angioplasty was associated with significantly lower MACE and improved NACE outcomes during follow-up compared with angiography‑guided therapy alone. This benefit was largely attributable to an improved safety profile (e.g., fewer bleeding events). The associations remained consistent across subgroups, suggesting that IVUS‑guided lesion preparation may offer clinical value in this population and warrants further investigation.
LaeknabladidTeitur Ari Theodorsson, Helgi Kristinn Sigmundsson, Thordis Jona Hrafnkelsdottir
CASE: A 46-year-old female presented to her general practitioner with abdominal pain, lethargy, dyspnea and pedal edema. Computed tomography (CT) revealed features of heart and liver failure with pleural fluid and ascites and the liver having a cirrhotic appearance. A gastroenterologist confirmed the diagnosis of cirrhosis, but the etiology was unknown. Pericardial calcifications and elevated jugular venous pressure on examination gave rise to a suspicion of constrictive pericarditis as the cause of the liver cirrhosis. Cardiac catheterization confirmed pericardial constriction, and the patient underwent a total pericardiectomy. DISCUSSION: It is easy to miss a diagnosis of constrictive pericarditis because it must be specifically sought after in the echocardiogram, and pericardial calcifications are only present in a minority of cases.
LaeknabladidKristjana Lind Olafsdottir, Luis Gisli Rabelo, Boðvar Pall Asgeirsson, Matthildur Maria Magnusdottir, Sigurdur Ragnarsson, Tomas Gudbjartsson
INTRODUCTION: Most studies comparing Off-pump and On-pump coronary artery bypass grafting (CABG) have primarily focused on short-term outcomes. The aim of this study was therefore to evaluate and compare long-term complications and survival between these surgical approaches. MATERIAL AND METHODS: This retrospective study included 2337 patients who underwent primary isolated CABG in Iceland between 2001-2021; 397 (17,0%) performed Off-Pump and 1940 (83,0%) On-Pump. The complications stroke, myocardial infarction (MI), percutaneous coronary intervention (PCI), repeat CABG and death; combined as major adverse cardiovascular and cerebrovascular events (MACCE), were compared between the groups after 1:1 propensity score matching (377 pairs). Long-term survival and MACCE-free survival were estimated using the Kaplan-Meier method and multivariable Cox regression. RESULTS: Before matching, patients in the On-Pump group had more extensive coronary artery disease and were more often operated on acutely. At 10-year follow-up, the cumulative incidence of PCI (14.0% in the Off-Pump group vs. 10.2% in the On-Pump group, p=0.110), MI (9.0% vs. 8.0%, p=0.784), stroke (4.6% vs. 6.8%, p=0.090) and repeat CABG (0.9% vs. 0.0%, p=0.090) were comparable between groups in the matched cohort. MACCE-free survival (71.0% in the Off-Pump group vs. 71.4% in the On-Pump group, p=0.74) and overall survival (78.5% vs. 73.2%, p=0.095) at 10 years was also comparable between groups. Furthermore, multivariate analysis showed similar overall survival for both surgical techniques (HR: 0.81; 95%-CI: 0.60-1.09; p=0,156). CONCLUSIONS: The long-term outcomes following CABG in Iceland are favorable for both Off-pump and On-pump procedures, both in terms of survival and long-term complications.
International wound journalLalita Jaingim, Kanlayanee Sittiwat, Kotchawan Nongyam, Konlawij Trongtrakul
Cold atmospheric plasma (CAP) therapy has emerged as a promising therapy for wound healing. This study aimed to evaluate the feasibility, safety and efficacy of adjunctive CAP therapy for early tracheostomy wound healing compared with standard wound care (SWC) alone. This single-centre, parallel-group pilot randomised controlled trial (1:1 allocation) enrolled critically ill patients undergoing tracheostomy. Patients received 1-min CAP applications on postoperative days 1, 3 and 5 plus SWC or SWC alone. The primary endpoint was the percentage reduction in tracheostomy wound area through postoperative day 7, assessed by a blinded outcome assessor. Due to the nature of the intervention, blinding of participants and treating clinicians was not feasible; however, the outcome assessor was blinded to group allocation. Wound healing trajectories were analysed using linear mixed-effects models adjusted for baseline wound area. Forty-two patients were included (CAP, n = 21; SWC, n = 21), with comparable baseline characteristics. By postoperative day 7, wound area reduction was greater in the CAP group than in the SWC group (30.3% vs. 23.6%, p = 0.15). Estimated wound area decreased by 0.08 versus 0.06 cm2/day (95% CI 0.06-0.10 and 0.04-0.08, respectively; p = 0.17). No treatment-related adverse events were observed. Adjunctive CAP therapy was feasible, safe and demonstrated a non-significant trend towards improved early tracheostomy wound healing. These findings support further evaluation in larger, adequately powered trials.
HLAAleksandra Gazikalovic, Christina Bade-Döding, Murielle Verboom, Susann Zirzow, Michael Hallensleben, Rainer Blasczyk, Jens Gottlieb, Funmilola Josephine Hauka…
ddcfDNA emerged as a biomarker for post-transplantation management strategies. Lung retransplant recipients represent a particularly vulnerable patient population with an increased risk of allograft injury. The demand for understanding if ddcfDNA levels differ between primary lung transplant recipients and lung retransplant recipients becomes obvious. Eight lung retransplant recipients and 50 primary lung transplant recipients with comparable HLA Class I and Class II mismatch scores were included in this retrospective study. During post-transplant monitoring, ddcfDNA results were evaluated alongside data on patient humoral immune responses pre- and post-transplantation. Antibody profiles of lung retransplant recipients did not differ significantly from those of their primary transplant comparisons. However, significantly higher ddcfDNA levels were observed in the retransplant cohort (median: 1.463%, IQR: 0.810-2.745) compared with primary transplant cohort (median: 0.550%, IQR: 0.338-0.935), U = 100.50, Z = -2.24, p = 0.012, r = 0.29. We identified that lung retransplant recipients exhibit increased allograft injury not solely attributable to humoral responses. Our study highlights that these patients face a higher immunological risk and supports the need for closer clinical follow-up using a resilient biomarker such as ddcfDNA. Incorporating ddcfDNA as a surrogate marker into post-transplant monitoring would provide early and unambiguous insights into allograft rejection, enabling prompt interventions to prevent unfavourable outcomes in this particularly fragile patient group.
Clinical transplantationFederico Franchi, Daniele Marianello, Cecilia Bianchi, Cesare Biuzzi, Leonardo Gottin, Lorenzo Peluso, Massimo Maccherini, Matteo Cameli, Igor Vendramin, Sabin…
Early postoperative heart rate (HR) management after heart transplantation (HTx) remains largely guided by historical haemodynamic concepts that support maintaining elevated HR to compensate for reduced stroke volume. This structured narrative review re-examines the physiological rationale and contemporary evidence underlying this approach, with the aim of refining perioperative chronotropic strategies. A comprehensive analysis of studies addressing early HR behavior, sinus node dysfunction (SND), pacing strategies, chronotropic therapies, and their association with clinical outcomes was performed. Classic studies from the 1970s described marked stroke-volume depression and a strong dependence of cardiac output on HR, forming the basis for maintaining HR around 90-100 bpm. However, contemporary evidence indicates a more heterogeneous early graft physiology, often with less pronounced stroke-volume limitation, and highlights potential adverse effects associated with excessive adrenergic stimulation, including renal dysfunction and worse mid-term outcomes. SND is common but typically transient, and atrial or atrioventricular-synchronous pacing can restore HR without the metabolic burden of β-adrenergic stimulation. In contrast, isoproterenol provides combined chronotropic and inotropic support but may increase myocardial oxygen consumption, shorten diastolic filling time, and impair right ventricular-pulmonary artery coupling when perfusion pressure is inadequate. Integration of perfusion markers, such as lactate and central venous oxygen saturation, with echocardiographic and invasive haemodynamic assessment is essential to determine whether HR augmentation improves oxygen delivery or instead increases metabolic stress. Early HR management after HTx should therefore be individualized and guided by integrated physiological assessment rather than fixed HR targets. Prospective studies are needed to define evidence-based chronotropic strategies.
OBJECTIVE: The radiological severity of thoracic disc herniation (TDH) has been an important factor in determining surgical strategy, especially in centrally located, calcified, or giant lesions. However, it is unclear whether radiological severity alone indicates an open transthoracic approach in myelopathic TDH. In this study, authors compared outcomes between transthoracic surgery and transforaminal endoscopic thoracic discectomy (TETD) and determined whether radiological severity is associated with the surgical approach selection. METHODS: The records of consecutive patients who underwent open transthoracic surgery or TETD for symptomatic TDH between 2007 and 2025 were retrospectively reviewed. Only the patients with myelopathy due to isolated 1- or 2-level TDH were included after applying strict inclusion and exclusion criteria. Demographic, radiological, clinical, and perioperative variables were analyzed. Radiological TDH severity parameters included canal occupying ratio, disc calcification, subarachnoid space effacement grade, and intramedullary T2 high signal intensity. Neurological recovery was assessed according to changes in the modified Japanese Orthopaedic Association scale and visual analog scale scores. Multivariable logistic regression analysis was performed to determine whether imaging variables independently predicted selection of the surgical approach. RESULTS: A total of 24 patients were included, 14 in the TETD group and 10 in the transthoracic group. Radiological TDH severity parameters did not significantly differ between groups. Neurological recovery was comparable between approaches, whereas pain improvement was greater in the TETD group. Perioperative morbidity was significantly higher in the transthoracic group, including thoracic cavity-related complications (50% vs 0%) and dural tears (70% vs 0%). The transthoracic approach was also associated with a longer operative time and hospital stay. Multivariable analysis showed that none of the radiological variables was associated with selection of the surgical approach. CONCLUSIONS: Radiological TDH severity did not differ between the 2 groups and was not associated with the choice of surgical approach. Neurological outcomes were comparable between the groups, while perioperative morbidity was higher in the transthoracic group. These findings suggest that radiological severity alone may not be enough to determine the surgical approach in TDH and that TETD may be considered in carefully selected patients with myelopathic TDH when adequate decompression is achievable.
Clinical transplantationAlexa Lavergne, Kirti Magudia, Tommi Jarvinen, Alexander Reed, Samantha Morrison, Mustafa R Bashir, Michael Rosenthal, Mohamed Sobhi Jabal, John M Reynolds, Br…
BACKGROUND: Lung transplantation is a complex therapy for end stage lung disease with variable postoperative outcomes. Textbook outcomes, defined by freedom from perioperative morbidity and mortality, have emerged as a comprehensive measure of surgical success. Body mass index (BMI) is commonly used to assess nutritional status but does not distinguish between skeletal muscle and adipose tissue. CT-based body composition analysis can differentiate these tissues and may provide a more precise assessment of physiologic reserve in lung transplantation. METHODS: We performed a retrospective cohort study of 377 adults undergoing single or bilateral lung transplantation at a single academic institution (2019-2023). Preoperative abdominal CT scans were used to quantify skeletal muscle, subcutaneous fat, and visceral fat areas. A composite textbook outcome was defined as freedom from intraoperative complications; postoperative reintervention; readmission, acute rejection, and dialysis within 30 days; 90-day mortality; primary graft dysfunction; ECMO at 72 h; tracheostomy within 7 days; reintubation; and extubation >48 h. Multivariable logistic regression assessed associations between body composition metrics and lung transplant outcomes after adjusting for potential confounders. RESULTS: Among 377 recipients, 108 (28.6%) achieved textbook outcome. Increased skeletal muscle area was associated with increased odds of achieving textbook outcome (OR per 50cm2: 1.808 [1.061-3.119]) and decreased odds of 1-year mortality (OR per 50cm2: 0.423 [0.195-0.890]). Subcutaneous fat area, visceral fat area, and BMI were not significantly associated with outcomes. CONCLUSION: CT-based skeletal muscle was associated with textbook outcome and 1-year mortality, whereas BMI was not. CT-based body composition analysis may be a promising tool for lung transplant risk stratification.
Physiotherapy research international : the journal for researchers and clinicians in physical therapyNeha Thakare, Manish Prannath Shukla, Vaibhav Kapre
BACKGROUND & PURPOSE: Patients with diabetes mellitus undergoing coronary artery bypass grafting (CABG) with saphenous vein harvesting are at increased risk of impaired lower extremity perfusion and wound-related complications. Buerger-Allen exercises have been proposed to improve peripheral circulation; however, evidence supporting their effectiveness following CABG remains limited. This study evaluated the effect of Buerger-Allen exercises as an adjunct to phase I cardiac rehabilitation on lower extremity perfusion and wound healing in diabetic patients undergoing CABG. METHODS: A randomized controlled trial was conducted involving 60 diabetic patients undergoing CABG with saphenous vein harvesting. Participants were randomly allocated to an intervention group receiving standard phase I cardiac rehabilitation plus Buerger-Allen exercises (n = 30) or a control group receiving standard rehabilitation alone (n = 30). The primary outcome was ankle-brachial index (ABI). Secondary outcomes included wound healing disturbances and peripheral ankle swelling. Postoperative ABI was analyzed using two-way repeated-measures ANOVA, whereas categorical outcomes were analyzed using Fisher's exact test or the Chi-squared test. RESULTS: A significant effect of time on ABI was observed (p = 0.004), whereas neither the group effect (p = 0.754) nor the group × time interaction (p = 0.711) was statistically significant. An earlier resolution of mild wound-related pain was observed on postoperative day 3 in the intervention group (p = 0.038); however, no between-group differences were present on postoperative day 5. No intervention-related adverse events were reported. DISCUSSION: Buerger-Allen exercises were safe and feasible during early postoperative rehabilitation but did not provide additional improvement in lower extremity perfusion beyond standard rehabilitation during the 5-day postoperative period. The isolated improvement in wound-related pain should be interpreted cautiously. CONCLUSION: Buerger-Allen exercises did not significantly improve the primary outcome of lower extremity perfusion following CABG. Although they appeared safe and were associated with transient improvement in wound-related pain, further adequately powered studies with longer follow-up are required to determine whether clinically meaningful benefits exist. TRIAL REGISTRATION: This study was prospectively registered in the Clinical Trial Registry India (CTRI/2023/10/058535).
Physiotherapy research international : the journal for researchers and clinicians in physical therapyBruna Elise da Silva Messias, Thamires Alessandra Silveira da Silva, Rafaela Anversa Schreiner, Letícia Torres, Jéssica Bischoff, Taís Flores de Oliveira, Vini…
BACKGROUND AND PURPOSE: This study investigated the effects of combining incentive spirometry with cardiac rehabilitation compared with cardiac rehabilitation alone on postoperative pulmonary complications, clinical-functional recovery, and hospital length of stay in patients undergoing cardiac surgery. METHODS: Randomized controlled trial was conducted from May 2019 to October 2023 in two hospitals, including 46 inpatients undergoing cardiac surgery. Participants were assigned to incentive spirometry plus cardiac rehabilitation or cardiac rehabilitation alone. Both interventions were performed twice daily; spirometry used a volume-oriented device, and rehabilitation followed a seven-step protocol (2-4 METs). Outcomes included postoperative pulmonary complications, functional capacity (6-min walk test), handgrip strength, respiratory muscle function, and length of hospital stay. RESULTS: The incentive spirometry associated with cardiac rehabilitation group had a longer extracorporeal circulation time (98 ± 26 min) than the cardiac rehabilitation group (76 ± 1; p = 0.008). Both groups showed a postoperative decline in respiratory muscle strength, and walking distance (MD: -64.37 m; 95% CI: [-24.1; -104.6]; d = 0.71), with no difference in postoperative pulmonary complications and handgrip strength. The incentive spirometry associated with cardiac rehabilitation group did not significantly differ on postoperative hospital stay compared with the cardiac rehabilitation group (MD: -1 day; 95% CI: [-4.71; 2.71]; d = -0.19). CONCLUSIONS: In this study, no additional benefit was observed with the addition of incentive spirometry to cardiac rehabilitation compared with cardiac rehabilitation alone. No significant differences were detected between groups in postoperative pulmonary complications, hospital length of stay, or clinical-functional recovery among individuals undergoing cardiac surgery. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials (REBEC) under the number RBR-8tsjf97.
Rhode Island medical journal (2013)Daniel Idoate Domench, Robin Reid, Dua Azim, Syed Ehsanullah, Aditya Sanjeevi, Aniket Rao
Factor V deficiency is a rare autosomal recessive bleeding disorder marked by impaired thrombin generation and variable bleeding risk. Perioperative management becomes particularly challenging in high-risk surgeries, such as aortic valve replacement, due to the absence of targeted replacement therapies and the limited efficacy of fresh frozen plasma (FFP) in restoring factor V levels. We report the case of a 30-year-old woman with congenital factor V deficiency (baseline activity 18%) who underwent successful mechanical aortic valve replacement and mitral valve repair for infective endocarditis. She received preoperative FFP aiming for a factor V level >20%. Her perioperative management included careful monitoring with a total of 23 units of FFP administered. Despite persistently low postoperative f levels (<20%), she experienced minimal bleeding complications, limited to transient anemia and one episode of gross hematuria requiring platelet transfusion. Outpatient follow-up revealed heterozygosity for both factor V Leiden and a prekallikrein variant, potentially explaining her relatively mild bleeding phenotype. This case highlights the disconnect that may exist between laboratory values and clinical bleeding risk, emphasizing the need for individualized perioperative planning and cautious anticoagulation management.
AIM: To evaluate the impact of a 12-element nurse-led tracheostomy care bundle, compared with routine care, on stoma integrity, respiratory distress, and pneumonia-related outcomes among patients with tracheostomies. DESIGN: A quasi-experimental study was conducted among 80 critically ill patients with tracheostomies admitted to Mansoura University Hospital. Participants were allocated into a study group receiving a 12-element nurse-led tracheostomy care bundle and a control group receiving routine care (40 patients per group). Patients were followed for 15 days. Data were collected using stoma-site assessment, the National Early Warning Score (NEWS), the Respiratory Distress Observation Scale (RDOS), and the modified Clinical Pulmonary Infection Score (CPIS). Statistical analyses included chi-squared tests, Friedman tests for repeated measurements, and effect size estimation using partial eta squared. RESULTS: Baseline demographic and clinical characteristics were comparable between groups (p > 0.05). Primary longitudinal repeated-measures models revealed significant Group × Time interaction effects favouring the nurse-led bundle for physiological stability (NEWS: F = 7.838, p < 0.001, partial eta squared = 0.086), stoma integrity composite scores (F = 5.849, p < 0.001, partial eta squared = 0.048), and respiratory distress trajectories (RDOS: F = 4.382, p = 0.014, partial eta squared = 0.036). Secondary day-specific analyses showed lower stoma-site infection signs (swelling, purulent discharge, skin breakdown, redness, warmth, and foul drainage) in the intervention cohort during follow-up. Regarding pneumonia-related outcomes, CPIS-indicated suspected respiratory infection occurred less frequently in the study group (1-week: 10.0% vs. 20.0%; 2-week: 5.0% vs. 10.0%), though the difference was not statistically significant (Chi-square = 3.710, p = 0.168). CONCLUSIONS: A 12-element nurse-led tracheostomy care bundle was associated with improved stoma integrity, reduced observed respiratory distress, and favourable changes in physiological stability among patients with tracheostomies. Although lower proportions of CPIS-indicated suspected respiratory infection were observed in the bundle group, the difference was not statistically significant. Further multicentre controlled studies are required to determine the effect of standardized tracheostomy care bundles on pneumonia-related outcomes. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: Standardizing tracheostomy management via a nurse-led bundle provides a structured, evidence-informed framework for ICU practice. For nurses, it ensures consistent airway management, stoma assessment, suctioning, humidification, cuff pressure monitoring, and documentation, enhancing procedural fidelity and patient safety. For patients, bundle adherence supports stoma integrity, reduces respiratory distress, and promotes physiological stability. These improvements may optimize ICU workflows, guide timely interventions, and support care transitions such as decannulation and discharge. Implementation should include staff training, standardized checklists, and monitoring to ensure fidelity and adaptability. While preliminary results are promising, further evaluation in diverse clinical settings is recommended before broad adoption. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.
Pediatric transplantationAkosua Dansoa Odei, Haoran Jiang, Natasha Anders, Seth Erasmus Murray Wolf, Chelsea Harris, Rebekah Boyd, Matthew Galen Hartwig, Douglas Marvin Overbey, Joseph…
BACKGROUND: Heart transplantation is definitive therapy for children with end-stage heart failure. Because donor availability is unpredictable, transplantation occurs overnight or on weekends. Although studies report mixed findings on the association between operative timing and outcomes, pediatric data remain limited. We evaluated the impact of operative timing on pediatric heart transplant outcomes. METHODS: We studied pediatric heart transplant recipients (< 18 years) in the United Network for Organ Sharing registry from 2000 to 2018. Transplants were classified by time of day (day: 9 AM-8:59 PM; night: 9 PM-8:59 AM) and day of week (weekday vs. weekend). Primary outcome was survival. Secondary outcomes included graft survival, rejection, retransplantation, and postoperative complications. Survival was analyzed using Kaplan-Meier and log-rank testing. Multivariable Cox regression adjusted for recipient and donor characteristics and pre-transplant support. RESULTS: Among 6125 recipients, 2930 (47.8%) transplants occurred during the day and 3195 (52.2%) at night; 4408 (72.0%) occurred on weekdays and 1717 (28.0%) on weekends. Kaplan-Meier analysis demonstrated no significant survival difference between daytime and nighttime transplants (p = 0.266) or weekday and weekend transplants (p = 0.210). In multivariable Cox regression, operative timing was not associated with mortality (night vs. day: hazard ratio 0.97, 95% confidence interval 0.89-1.06, p = 0.554; weekend versus weekday: hazard ratio 1.04, 95% confidence interval 0.94-1.15, p = 0.445). Acute rejection prior to discharge and treatment for rejection within 1 year was more frequent in daytime transplants without affecting graft survival. CONCLUSIONS: Operative timing was not associated with patient survival, graft survival, or postoperative outcomes after pediatric heart transplantation.
Respiratory cultures before and after lung transplantation are frequently obtained but often difficult to interpret. A positive culture may represent donor-derived organisms, recipient reservoir recolonization, hospital acquisition, transient colonization, invasive infection, or a marker of evolving graft vulnerability. This review summarizes how respiratory microbiology changes across the lung transplant timeline and proposes a practical framework for clinical interpretation. Conventional culture-based studies and recent airway microbiome literature are integrated to examine donor-recipient attribution, pre-transplant colonization, disease-specific reservoirs, single-lung transplantation, and pathogen-specific risk. Pre-transplant recipient colonization, particularly with multidrug-resistant gram-negative organisms, appears more consistently associated with early post-transplant pneumonia and short-term outcomes than donor culture positivity alone when targeted antimicrobial therapy is used. Disease-specific patterns are also important: cystic fibrosis and bronchiectasis favor recolonization from persistent reservoirs, whereas single-lung transplantation creates a dual-airway ecosystem in which the native lung may remain microbiologically relevant. Persistent or recurrent isolation of organisms such as Pseudomonas aeruginosa, Burkholderia cenocepacia, Staphylococcus aureus, Aspergillus species, and nontuberculous mycobacteria should be interpreted in relation to symptoms, imaging, lung function, sampling source, and timing from transplant. Contextual interpretation of respiratory cultures may improve antimicrobial planning, donor acceptance decisions, stewardship, and long-term graft surveillance.
Clinical transplantationJoseph Barile, Yanling Zhao, Ali Fatehi Hassanabad, Farhana Latif, Gabriel Sayer, Nir Uriel, Paul Kurlansky, Koji Takeda
BACKGROUND: Donation after circulatory death (DCD) has expanded the US heart donor pool yet carries a higher risk of severe primary graft dysfunction (PGD) for recipients compared to donation after brain death (DBD). This study addresses an important knowledge gap of exploring the role of heart size mismatch in contributing to the risk of severe PGD in DCD-HT. METHODS: All heart-only, adult transplants from the united network for organ sharing (UNOS) database were collected from 09/2023-06/2025. Univariable (UV) and multivariable (MV) analyses were used to identify associations between various size matching variables and severe PGD in both DCD-HT and DBD-HT. RESULTS: In the DCD-HT MV analysis, no categorical classifications of size mismatch had significant associations with severe PGD. However, various recipient size metrics, including predicted heart mass (PHM) (OR = 1.01 per gram [1.00-1.01], p = 0.002) were independently associated with severe PGD in DCD-HT. When analyzed in the dataset containing both DCD and DBD cases, PHM's association with severe PGD was found to interact with DCD status (β = 0.009, SE = 0.0032, p = 0.004). CONCLUSIONS: Conventional categorical donor-recipient size-mismatch classifications established in DBD-HT were not associated with severe PGD in DCD-HT. In contrast, larger recipient size was independently associated with an increased risk of severe PGD in DCD-HT, whereas no such association was observed in DBD-HT. These findings highlight potential differences in the determinant of severe PGD between DCD-HT and DBD-HT and support further investigation into the role of recipient size in donor-recipient matching for DCD-HT.
BACKGROUND/AIM: With the aging population, thoracic surgeons increasingly encounter patients with primary lung cancer who have a history of prior extrapulmonary malignancy (PEM). We investigated whether PEM independently compromises survival after curative-intent lung cancer resection and whether any difference is explained by impaired cancer control or competing mortality. PATIENTS AND METHODS: We retrospectively analyzed 1,857 consecutive lung cancer resections performed in 2017-2018 at 12 Yokohama City University-affiliated institutions. After exclusion of 74 patients with prior lung cancer only, 1,783 patients remained: 505 in the PEM group and 1,278 in the no prior extrapulmonary malignancy (NPEM) group. Overall survival (OS), recurrence-free survival (RFS), inverse probability of treatment weighting (IPTW)-adjusted outcomes, and Fine-Gray competing-risk analyses were evaluated. RESULTS: Compared with the NPEM group, the PEM group was older and included higher proportions of men, ever-smokers, patients diagnosed during surveillance for other diseases, and patients treated with limited resection. Unadjusted 5-year OS was 80.43% in the PEM group and 81.42% in the NPEM group (p=0.092), whereas 5-year RFS was 68.76% and 68.52%, respectively (p=0.983). PEM was not independently associated with OS [hazard ratio (HR)=1.046, 95% confidence interval (CI)=0.825-1.326, p=0.712] or RFS (HR=0.970, 95%CI=0.798-1.178, p=0.756). IPTW-adjusted analyses were concordant. Fine-Gray models showed no significant association between PEM and lung cancer-related death or non-lung-cancer death. CONCLUSION: PEM did not independently worsen postoperative cancer control or survival after lung cancer resection. Curative-intent surgery should therefore be considered according to the biology and operability of the current lung cancer rather than prior cancer history alone.
Yonsei medical journalKina Jeon, Hyeongsu Kim, Chul Kim, Kunsei Lee, Bora Lee, Ho Jin Jeong, Sung Hea Kim, Kyeong Eun Uhm
PURPOSE: Cardiac rehabilitation (CR) is central to tertiary prevention after acute myocardial infarction (AMI), but the prognostic impact of different education and therapy patterns in Asian real world practice is uncertain. MATERIALS AND METHODS: Using Korean National Health Insurance Service claims (2018-2022), we identified patients aged ≥40 years hospitalized for AMI who underwent thrombolysis, percutaneous coronary intervention, or coronary artery bypass grafting. CR exposure was classified into six groups by structured education and the number of supervised therapy sessions, and outcomes over 2 years included all cause readmission, readmission and emergency room (ER) visits for MI or unstable angina (UA), all cause mortality, repeat revascularization, and stroke. Multivariable Cox models estimated adjusted hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS: Among 92968 patients, 85.5% received no CR, 3.2% had education only, and 11.3% received any therapy. Education only participants had the lowest crude rates of mortality, cardiovascular readmission, and repeat revascularization. All CR exposed groups showed lower all cause mortality, with the greatest benefit in education plus ≥4 therapy sessions (HR 0.257, 95% CI 0.123-0.539) and ≥4 therapy sessions without education (HR 0.291, 95% CI 0.203-0.417). Education focused CR was additionally associated with lower cardiovascular readmission and repeat revascularization, whereas readmission and ER visits varied across therapy intensive groups. CONCLUSION: In this nationwide Korean AMI cohort, CR participation, especially with education, was associated with substantial mortality reduction, suggesting structured education as a pragmatic cornerstone of tertiary prevention, with supervised therapy providing incremental benefit when available.
Critical care nurseZachary Feldt, John McNeil, Neal Parikh, Janelle Georgiana, Paul D Gallo
BACKGROUND: Regional anesthesia techniques are becoming increasingly used to reduce postoperative pain, reduce opioid use, and improve other outcomes in patients undergoing cardiac surgery. OBJECTIVE: To provide critical care nurses with an overview of regional anesthesia techniques for cardiac surgery patients and to discuss considerations for bedside nurses to ensure safe, effective, and patient-centered care. METHODS: A review of current literature was performed to provide a summary of fascial plane block techniques and the benefits, risks, and implications of their use for patients undergoing cardiac surgery. The role of bedside critical care nurses was examined. RESULTS: Regional anesthesia has been shown to improve postoperative pain scores, shorten intensive care unit and hospital stays, reduce several postoperative complications, and improve other patient-centered outcomes for cardiac surgery patients. Critical care nurses perform crucial roles during placement of the blocks, when monitoring patients for adverse effects of local anesthesia, and by providing patient education and managing patients' expectations. DISCUSSION: Regional anesthesia is an important tool in the care of patients undergoing cardiac surgery, and studies support its benefits for patient outcomes. However, further research is needed to develop and optimize evidence-based protocols for clinicians and perioperative care teams. CONCLUSION: As regional anesthesia becomes a routine component of post-cardiac surgery care, critical care nurses must be familiar with block techniques (administration and implication), monitoring protocols, and management of potential adverse events to optimize patient outcomes.