A country level exploratory analysis was conducted to assess the impact of timing and type of national health policy/actions undertaken towards COVID-19 mortality and related health outcomes.
...Information on COVID-19 policies and health outcomes were extracted from websites and country specific sources. Data collection included the government's action, level of national preparedness, and country specific socioeconomic factors. Data was collected from the top 50 countries ranked by number of cases. Multivariable negative binomial regression was used to identify factors associated with COVID-19 mortality and related health outcomes.
Increasing COVID-19 caseloads were associated with countries with higher obesity (adjusted rate ratio RR=1.06; 95%CI: 1.01–1.11), median population age (RR=1.10; 95%CI: 1.05–1.15) and longer time to border closures from the first reported case (RR=1.04; 95%CI: 1.01–1.08). Increased mortality per million was significantly associated with higher obesity prevalence (RR=1.12; 95%CI: 1.06–1.19) and per capita gross domestic product (GDP) (RR=1.03; 95%CI: 1.00–1.06). Reduced income dispersion reduced mortality (RR=0.88; 95%CI: 0.83–0.93) and the number of critical cases (RR=0.92; 95% CI: 0.87–0.97). Rapid border closures, full lockdowns, and wide-spread testing were not associated with COVID-19 mortality per million people. However, full lockdowns (RR=2.47: 95%CI: 1.08–5.64) and reduced country vulnerability to biological threats (i.e. high scores on the global health security scale for risk environment) (RR=1.55; 95%CI: 1.13–2.12) were significantly associated with increased patient recovery rates.
In this exploratory analysis, low levels of national preparedness, scale of testing and population characteristics were associated with increased national case load and overall mortality.
This study is non-funded.
Albumin in adult cardiac surgery: a narrative review Hanley, Ciara; Callum, Jeannie; Karkouti, Keyvan ...
Canadian journal of anaesthesia/Canadian journal of anesthesia,
08/2021, Volume:
68, Issue:
8
Journal Article
Peer reviewed
Open access
Purpose
Intravascular fluids are a necessary and universal component of cardiac surgical patient care. Both crystalloids and colloids are used to maintain or restore circulating plasma volume and ...ensure adequate organ perfusion. In Canada, human albumin solution (5% or 25% concentration) is a colloid commonly used for this purpose. In this narrative review, we discuss albumin supply in Canada, explore the perceived advantages of albumin, and describe the clinical literature supporting and refuting albumin use over other fluids in the adult cardiac surgical population.
Source
We conducted a targeted search of PubMed, Embase, Medline, Web of Science, ProQuest Dissertations and Theses Global, the Cochrane Central Register of Controlled trials, and the Cochrane Database of Systematic Reviews. Search terms included
albumin, colloid, cardiac surgery, bleeding, hemorrhage, transfusion,
and
cardiopulmonary bypass.
Principal findings
Albumin is produced from fractionated human plasma and imported into Canada from international suppliers at a cost of approximately $21 million CAD per annum. While it is widely used in cardiac surgical patients across the country, it is approximately 30-times more expensive than equivalent doses of balanced crystalloid solutions, with wide inter-institutional variability in use and no clear association with improved outcomes. There is a general lack of high-quality evidence for the superiority of albumin over crystalloids in this patient population, and conflicting evidence regarding safety.
Conclusions
In cardiac surgical patients, albumin is widely utilized despite a lack of high- quality evidence supporting its efficacy or safety. A well-designed randomized controlled trial is needed to clarify the role of albumin in cardiac surgical patients.
Purpose
The mainstay of therapy for coagulation factor deficiency in cardiac surgical patients is frozen plasma (FP); however, prothrombin complex concentrates (PCCs) may offer logistical and safety ...advantages. As there is limited comparative evidence, we conducted this study to explore the association of comparable PCC or FP doses with transfusion and outcomes.
Methods
This was a post hoc analysis of a multicentre randomized trial comparing fibrinogen concentrate with cryoprecipitate (FIBRES trial) in bleeding cardiac surgical patients. This analysis included 415 patients who received only PCC (
n
= 72; 17%) or only FP (
n
= 343; 83%) for factor replacement. The main outcomes of interest were red blood cell (RBC) and platelet transfusion within 24 hr of cardiopulmonary bypass. Secondary outcomes included postoperative adverse events. Associations were examined by hierarchical generalized estimating equation models adjusted for demographic and surgical characteristics.
Results
The median interquartile range (IQR) PCC dose was 1,000 1,000–2,000 units, while the median IQR FP dose was 4 2–6 units. Each unit of FP was independently associated with increased adjusted odds of RBC (1.60; 95% confidence interval CI, 1.36 to 1.87;
P
< 0.01) and platelet transfusion (1.40; 95% CI, 1.15 to 1.69;
P
< 0.01) while each 500 units of PCC was independently associated with reduced adjusted odds of RBC (0.67; 95% CI, 0.50 to 0.90;
P
< 0.01) and platelet transfusion (0.80; 95% CI, 0.70 to 0.92;
P
< 0.01). Adverse event rates were comparable.
Conclusions
In cardiac surgical patients with post-cardiopulmonary bypass bleeding, PCC use was associated with lower RBC and platelet transfusion than FP use was. Prospective, randomized clinical trials comparing FP with PCC in this setting are warranted.
Osteoarthritis is associated with the irreversible degeneration of articular cartilage. Notably, in this condition, articular cartilage chondrocytes undergo phenotypic and gene expression changes ...that are reminiscent of their end-stage differentiation in the growth plate during skeletal development. Hedgehog (Hh) signaling regulates normal chondrocyte growth and differentiation; however, the role of Hh signaling in chondrocytes in osteoarthritis is unknown. Here we examine human osteoarthritic samples and mice in which osteoarthritis was surgically induced and find that Hh signaling is activated in osteoarthritis. Using several genetically modified mice, we found that higher levels of Hh signaling in chondrocytes cause a more severe osteoarthritic phenotype. Furthermore, we show in mice and in human cartilage explants that pharmacological or genetic inhibition of Hh signaling reduces the severity of osteoarthritis and that runt-related transcription factor-2 (RUNX2) potentially mediates this process by regulating a disintegrin and metalloproteinase with thrombospondin type 1 motif-5 (ADAMTS5) expression. Together, these findings raise the possibility that Hh blockade can be used as a therapeutic approach to inhibit articular cartilage degeneration.
Cardiopulmonary bypass (CPB) has allowed for significant surgical advancements, but accompanying risks can be significant and must be expertly managed. One of the foremost risks is coagulopathic ...bleeding. Increasing levels of bleeding in cardiac surgical patients at the time of separation from CPB are associated with poor outcomes and mortality. CPB‐associated coagulopathy is typically multifactorial and rarely due to inadequate reversal of systemic heparin alone. The components of the bypass circuit induce systemic inflammation and multiple disturbances of the coagulation and fibrinolytic systems. Anticipating coagulopathy is the first step in managing it, and specific patient and procedural risk factors have been identified as predictors of excessive bleeding. Medication management pre‐procedure is critical, as patients undergoing cardiac surgery are commonly on anticoagulants or antiplatelet agents. Important adjuncts to avoid transfusion include antifibrinolytics, and perfusion practices such as red cell salvage, sequestration, and retrograde autologous priming of the bypass circuit have varying degrees of evidence supporting their use. Understanding the patient's coagulation status helps target product replacement and avoid larger volume transfusion. There is increasing recognition of the role of point‐of‐care viscoelastic and functional platelet testing. Common pitfalls in the management of post‐CPB coagulopathy include overdosing protamine for heparin reversal, imperfect laboratory measures of thrombin generation that result in normal or near‐normal laboratory results in the presence of continued bleeding, and delayed recognition of surgical bleeding. While challenging, the effective management of CPB‐associated coagulopathy can significantly improve patient outcomes.
Hypofibrinogenaemia is associated with excessive bleeding after cardiac surgery. Our aim was to compare the efficacy and safety of weight-adjusted vs empiric dosing of fibrinogen replacement in ...cardiac surgery.
In the Fibrinogen Replenishment in Cardiac Surgery (FIBRES) RCT, patients (n=735) received fibrinogen concentrate (4 g) or cryoprecipitate (10 units). In this post-hoc analysis, patients were grouped into quartiles based on increasing weight-adjusted dosing. Generalised estimating equations were used to account for hospital site, age, sex, surgical complexity, urgency, and critical preoperative status. The primary outcome was the number of units of red blood cells transfused within 24 h of cardiopulmonary bypass. Secondary outcomes included allogeneic blood components within 24 h, tamponade or major bleeding, and thromboembolic complications, ischaemic complications, or both within 28 days of cardiopulmonary bypass.
The median weight-adjusted doses were 52 mg kg−1 of fibrinogen concentrate (inter-quartile range IQR, 45–61; n=372) and 1.30 units per 10 kg of cryoprecipitate (IQR, 1.11–1.54; n=363). When patients were divided into quartiles of lowest to highest weight-adjusted dosing, no differences were seen in the primary outcome of red blood cell units transfused within 24 h of cardiopulmonary bypass between the lowest and highest quartiles in either the fibrinogen group (adjusted relative risk RR=0.90; 95% confidence interval CI, 0.71–1.13; P=0.36) or the cryoprecipitate group (adjusted RR=1.04; 95% CI, 0.76–1.43; P=0.80). Results were similar for all secondary outcomes.
Outcomes for the lowest and highest weight-adjusted doses of fibrinogen replacement were comparable. Weight-adjusted dosing does not appear to offer advantages over empiric dosing in this context.
NCT03037424.
Background Platelets stored at 1-6 degreesC are hypothesized to be more hemostatically active than standard room temperature platelets (RTP) stored at 20-24 degreesC. Recent studies suggest ...converting RTP to cold-stored platelets (Delayed Cold-Stored Platelets, DCSP) may be an important way of extending platelet lifespan and increasing platelet supply while also activating and priming platelets for the treatment of acute bleeding. However, there is little clinical trial data supporting the efficacy and safety of DCSP compared to standard RTP. Methods This protocol details the design of a multicentre, two-arm, parallel-group, randomized, active-control, blinded, internal pilot trial to be conducted at two cardiac surgery centers in Canada. The study will randomize 50 adult (greater than or equal to 18 years old) patients undergoing at least moderately complex cardiac surgery with cardiopulmonary bypass and requiring platelet transfusion to receive either RTP as per standard of care (control group) or DCSP (intervention group). Patients randomized to the intervention group will receive ABO-identical, buffy-coat, pathogen-reduced, platelets in platelet additive solution maintained at 22 degreesC for up to 4 days then placed at 4 degreesC for a minimum of 24 h, with expiration at 14 days after collection. The duration of the intervention is from the termination of cardiopulmonary bypass to 24 h after, with a maximum of two doses of DCSP. Thereafter, all patients will receive RTP. The aim of this pilot is to assess the feasibility of a future RCT comparing the hemostatic effectiveness of DCSP to RTP (defined as the total number of allogeneic blood products transfused within 24 h after CPB) as well as safety. Specifically, the feasibility objectives of this pilot study are to determine (1) recruitment of greater than or equal to 15% eligible patients per center per month); (2) appropriate platelet product available for greater than or equal to 90% of patients randomized to the cold-stored platelet group; (3) Adherence to randomization assignment (> 90% of patients administered assigned product). Discussion DCSP represents a promising logistical solution to address platelet supply shortages and a potentially more efficacious option for the management of active bleeding. No prospective clinical studies on this topic have been conducted. This proposed internal pilot study will assess the feasibility of a larger definitive study. Trial registration NCT 06147531 (clinicaltrials.gov). Keywords: Cold-stored platelets, Cardiac surgery, Transfusion, Hemostasis, Platelets, Thrombocytes
Background:
Evaluation of research productivity among plastic surgeons can be complex. The Hirsch index (h-index) was recently introduced to evaluate both the quality and quantity of one’s research ...activity. It has been proposed to be valuable in assessing promotions and grant funding within academic medicine, including plastic surgery. Our objective is to evaluate research productivity among Canadian academic plastic surgeons using the h-index.
Methods:
A list of Canadian academic plastic surgeons was obtained from websites of academic training programs. The h-index was retrieved using the Scopus database. Relevant demographic and academic factors were collected and their effects on the h-index were analyzed using the t test and Wilcoxon Mann-Whitney U test. Nominal and categorical variables were analyzed using χ2 test and 1-way analysis of variance. Univariate and multivariate models were built a priori. All P values were 2 sided, and P < .05 was considered to be significant.
Results:
Our study on Canadian plastic surgeons involved 175 surgeons with an average h-index of 7.6. Over 80% of the surgeons were male. Both univariable and multivariable analysis showed that graduate degree (P < .0001), academic rank (P = .03), and years in practice (P < .0001) were positively correlated with h-index. Limitations of the study include that the Scopus database and the websites of training programs were not always up-to-date.
Conclusion:
The h-index is a novel tool for evaluating research productivity in academic medicine, and this study shows that the h-index can also serve as a useful metric for measuring research productivity in the Canadian plastic surgery community. Plastic surgeons would be wise to familiarize themselves with the h-index concept and should consider using it as an adjunct to existing metrics such as total publication number.
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