A new emphasis has been directed toward “off-pump” coronary artery bypass grafting to avoid the morbidity of cardiopulmonary bypass and further reduce the postoperative hospital length of stay. With ...the intent of achieving a hospital discharge for “on-pump” coronary artery bypass grafting procedures comparable with the same procedures “off pump,” we applied a rapid-recovery protocol with particular attention paid to patients eligible for discharge on the third postoperative day.
The cases of 104 consecutive patients who underwent isolated coronary artery bypass grafting using cardiopulmonary bypass were retrospectively reviewed. A rapid-recovery protocol emphasizing reduced cardiopulmonary bypass time, an anesthesia protocol for early extubation, perioperative administration of corticosteroids and thyroid hormone, and aggressive diuresis was applied to all patients. The goal during the first 24 hours postoperatively was to achieve early extubation as well as a mild state of negative fluid balance and to ensure absence of postoperative bleeding and a safe transfer from the intensive care unit to a monitored floor. On the second postoperative day, chest drains were discontinued, and aggressive ambulation therapy was instituted. If at 72 hours postoperatively the patient was walking without assistance, had return of normal bowel function, and had no atrial fibrillation, a 3-day discharge home was planned.
The 30-day mortality rate for the entire group was 1.9%. The average postoperative hospital length of stay for the entire series was 4.8 ± 2.4 days. Of the 102 survivors, 30 patients (29%) were discharged within 3 days postoperatively (group 1), and 72 patients (71%) were discharged after the third postoperative day (group 2). Patients in group 1 were younger and had fewer comorbid conditions. Compared with group 2, group 1 had fewer patients with diabetes (7% versus 28%; p < 0.05), congestive heart failure (7% versus 18%), symptomatic vascular disease (0% versus 11%), chronic obstructive pulmonary disease (0% versus 10%), ambulatory difficulties (0% versus 10%), and the requirement of an intraaortic balloon pump preoperatively (13% versus 35%). Group 1 patients also had almost no complications and a lower readmission rate (3.3% versus 6.9%).
With the application of a rapid-recovery protocol to patients undergoing “on-pump” coronary artery bypass grafting, discharge home within 3 days postoperatively is attainable and safe for patients who have minimal comorbid conditions.
Recent studies have established that dysregulation of the human immune system and the reactivation of latent herpesviruses persists for the duration of a 6-month orbital spaceflight. It appears ...certain aspects of adaptive immunity are dysregulated during flight, yet some aspects of innate immunity are heightened. Interaction between adaptive and innate immunity also seems to be altered. Some crews experience persistent hypersensitivity reactions during flight. This phenomenon may, in synergy with extended duration and galactic radiation exposure, increase specific crew clinical risks during deep space exploration missions. The clinical challenge is based upon both the frequency of these phenomena in multiple crewmembers during low earth orbit missions and the inability to predict which specific individual crewmembers will experience these changes. Thus, a general countermeasure approach that offers the broadest possible coverage is needed. The vehicles, architecture, and mission profiles to enable such voyages are now under development. These include deployment and use of a cis-Lunar station (mid 2020s) with possible Moon surface operations, to be followed by multiple Mars flyby missions, and eventual human Mars surface exploration. Current ISS studies will continue to characterize physiological dysregulation associated with prolonged orbital spaceflight. However, sufficient information exists to begin consideration of both the need for, and nature of, specific immune countermeasures to ensure astronaut health. This article will review relevant in-place operational countermeasures onboard ISS and discuss a myriad of potential immune countermeasures for exploration missions. Discussion points include nutritional supplementation and functional foods, exercise and immunity, pharmacological options, the relationship between bone and immune countermeasures, and vaccination to mitigate herpes (and possibly other) virus risks. As the immune system has sentinel connectivity within every other physiological system, translational effects must be considered for all potential immune countermeasures. Finally, we shall discuss immune countermeasures in the context of their individualized implementation or precision medicine, based on crewmember specific immunological biases.
Hemingway and Italy MARK CIRINO; MARK P. OTT
Hemingway and Italy,
07/2017
Book Chapter
One of the strangest moments of dialogue in any piece of Hemingway’s writing appears in Across the River and into the Trees, Hemingway’s maligned 1950 novel about a dying American colonel and his ...doomed love for Renata, an eighteen-year-old Italian contessa. In this bizarre but pointed stretch of dialogue, by expressing his devotion to Venice, the dying Colonel Cantwell exchanges unspoken subtleties with Barone Alvarito, the young man who, it is implied, will assume a relationship with the love of Cantwell’s life after he dies. In classic Hemingway style, the true issue is not confronted directly, but rather through suggestion.
In late December 2019, a cluster of cases of pneumonia of unknown etiology were reported linked to a market in Wuhan, China
. The causative agent was identified as the species Severe acute ...respiratory syndrome-related coronavirus and was named SARS-CoV-2 (ref.
). By 16 April the virus had spread to 185 different countries, infected over 2,000,000 people and resulted in over 130,000 deaths
. In the Netherlands, the first case of SARS-CoV-2 was notified on 27 February. The outbreak started with several different introductory events from Italy, Austria, Germany and France followed by local amplification in, and later also outside, the south of the Netherlands. The combination of near to real-time whole-genome sequence analysis and epidemiology resulted in reliable assessments of the extent of SARS-CoV-2 transmission in the community, facilitating early decision-making to control local transmission of SARS-CoV-2 in the Netherlands. We demonstrate how these data were generated and analyzed, and how SARS-CoV-2 whole-genome sequencing, in combination with epidemiological data, was used to inform public health decision-making in the Netherlands.
Folder 727 of the John F. Kennedy Library's Hemingway Collection contains an unpublished, one-paragraph fragment describing a cold wind blowing the dust off a road and a bridge. Both the catalog and ...Paul Smith identify the fragment as belonging to the short story "Che Ti Dice Ia Patria?" Together, fragment and published short story reveal Hemingway at an intriguing artistic crossroads. Their imagery reverberates from Hemingway's earlier Nick Adams stories through his novel A Farewell to Arms to his late memoir A Moveable Feast. PUBLICATION ABSTRACT
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