Tennessee medicine : journal of the Tennessee Medical Association, 2003
Topical and local anesthetics are employed during minor invasive procedures to increase patient t... more Topical and local anesthetics are employed during minor invasive procedures to increase patient tolerance and to reduce the need for intravenous sedation. A potentially fatal complication of these anesthetics is methemoglobinemia (Met-Hgb). Met-Hgb should be suspected in patients with cyanosis that does not respond to administration of oxygen and who have a discrepancy in oxygen saturation measured by pulse oximetry compared with the arterial partial pressure of oxygen (PaO2) determined by blood gas analysis. We present a patient who developed life-threatening Met-Hgb from the local anesthesia required during percutaneous endoscopic gastrostomy tube placement.
Gallbladder cancer is found in about 1-2% of patients after laparoscopic cholecystectomy and it i... more Gallbladder cancer is found in about 1-2% of patients after laparoscopic cholecystectomy and it is difficult to diagnose preoperatively. Laparoscopic cholecystectomy may disseminate gallbladder cancer to peritoneum and even port sites. Here, we present a case of a 59-year-old female patient operated for gallstone disease and her histopathology was suggestive of well-diffentiated gallbladder carcinoma (T1N0M0). Patient presented to us with port site and distant peritoneal metastases after 3 months.
International journal of preventive medicine, 2014
India shares the largest burden of under-nutrition in world. The aim of this study was to conduct... more India shares the largest burden of under-nutrition in world. The aim of this study was to conduct follow-up assessment of under-nourished children attending anganwadi center (AWC). This was a retrospective cohort study conducted in 50 AWC of Tapi district. Total 529 children aged 1-6 years diagnosed as under-nourished before 1 year were included. Pre-structured questionnaire was used for present day assessment of these children followed by Epi-info mediated analysis. Children of literate mothers had higher weight gain. Ninety percent of children attended anganwadi regularly, however 25% of children dropped out for more than 1 month. In 1 year, growth had faltered in 20% children and was stagnant in 63% of them. Children who were treated for under-nutrition; that completed course at Child Development and Nutrition Center; and whose parents were counseled about the under-nourished status of child had higher weight gain than their counterparts. Parents of under-nourished children must ...
Journal of Structural and Functional Genomics, 2010
The Scottish Structural Proteomics Facility was funded to develop a laboratory scale approach to ... more The Scottish Structural Proteomics Facility was funded to develop a laboratory scale approach to high throughput structure determination. The effort was successful in that over 40 structures were determined. These structures and the methods harnessed to obtain them are reported here. This report reflects on the value of automation but also on the continued requirement for a high degree of scientific and technical expertise. The efficiency of the process poses challenges to the current paradigm of structural analysis and publication. In the 5 year period we published ten peer-reviewed papers reporting structural data arising from the pipeline. Nevertheless, the number of structures solved exceeded our ability to analyse and publish each new finding. By reporting the experimental details and depositing the structures we hope to maximize the impact of the project by allowing others to follow up the relevant biology.
Downy mildew (Peronospora plantaginis) caused two different types of infection in the floral part... more Downy mildew (Peronospora plantaginis) caused two different types of infection in the floral parts of isabgol (Plantago ovata). Systemic infection resulted in long spikes bearing weak and sterile florets, which later turned black due to saprophytic growth. Localised infection produced various symptoms ranging between normal flower opening and failure to bloom. Different parts of infected flowers such as sepal, petal, filament and anther were reduced in size compared to healthy flowers. However, gynoecium was elongated in localised infection. P. plantaginis induced gradual sterility of isabgol flowers. Androecium was affected more than the gynoecium was. Pollen number, pollen viability and germination reduced drastically due to localised infection. On the contrary, there were no significant differences between healthy and locally infected flowers in terms of stigma receptivity. In systemically infected spikes, bud development was arrested leading to sterility. When localised disease severity was high, secondary systemic infection caused similar symptoms. Microscopic observations showed presence of the pathogen in different parts of the flowers. Downy mildew adversely affected seed yield and quality; producing seeds, which were smaller and lighter than the healthy ones and later, became black. Seed yield was reduced by as much as 73.45 percent. Husk content per unit seed mass increased relatively as the total surface area of infected seeds increased.
Under iron limitation, the Gram-positive bacterium Streptomyces coelicolor A3(2) excretes three s... more Under iron limitation, the Gram-positive bacterium Streptomyces coelicolor A3(2) excretes three siderophores of the hydroxamate type: desferrioxamine B, desferrioxamine E, and coelichelin. These sequester iron from insoluble ferric hydroxides, and the resulting ferric complexes are believed to be transported into the cell via siderophore-binding proteins (SBPs) associated with ATP-binding cassette (ABC) transporters. Previous studies indicated that some of the genes in the desferrioxamine (des) and coelichelin (cch) biosynthetic clusters encode ABC transporter components required for efficient uptake of ferrioxamine E and ferricoelichelin, respectively, and a third ABC transporter gene cluster (cdt), not associated with siderophore biosynthesis genes, was implicated in the import of ferrioxamine B. In this study, the putative SBPs associated with these three gene clusters, DesE, CchF, and CdtB, were recombinantly overproduced in Escherichia coli and purified to homogeneity, and their binding affinity for cognate siderophores and noncognate siderophores was examined using fluorescence and circular dichroism spectroscopy. DesE was found to bind all of the ferric-tris-hydroxamates tested except ferricoelichelin, while CchF was found to bind only ferricoelichelin efficiently, providing further evidence that the cch cluster is a complete siderophore biosynthesis-export-uptake gene cluster. The picture was more complicated for CdtB, because it was found to be unstable in solution but was found to bind both ferrioxamine B and ferricoelichelin with high affinity. This was surprising because the cch cluster was previously reported to be necessary for efficient ferricoelichelin uptake. The remarkable specificity of the DesE and CchF proteins for different ferric-tris-hydroxamates raises intriguing questions about the molecular basis of their substrate specificity.
Patients with an abdominal aortic aneurysm (AAA) could benefit from earlier diagnosis to improve ... more Patients with an abdominal aortic aneurysm (AAA) could benefit from earlier diagnosis to improve long-term outcomes. Candidate serum biomarkers for earlier AAA diagnosis include D-dimer, fibrinogen, low-density lipoprotein, high-density lipoprotein, lipoprotein(a), and the proteolytic enzymes known as matrix metalloproteinases. Furthermore, biomarkers such as brain natriuretic peptide significantly stratify perioperative risk in AAA repair. Statins significantly improve outcomes after AAA repair. They may also significantly slow AAA growth to allow pharmacologic arrest of AAA development. Recent trials have focused attention on fluid management for AAA repair. Although restrictive fluid management may significantly improve clinical outcomes, current evidence does not clearly support crystalloid or colloid for AAA repair. There may be an increased risk of renal dysfunction associated with hetastarch therapy. Endovascular repair has revolutionized the clinical management of AAAs. Recent trials have shown its significant outcome advantages. Furthermore, it is also applicable in high-risk operative cohorts and, in the future, may be suited for earlier AAA repair. This technology continues to advance with the development of branched and fenestrated grafts as well as total percutaneous endovascular AAA repair. Regardless of these advances, the clinical management of endoleaks will remain a major clinical focus. Taken together, these advances in the management of AAAs likely will significantly influence future clinical approaches to this challenging patient cohort.
Beyond cholesterol reduction, statins have multiple beneficial influences on vascular endothelial... more Beyond cholesterol reduction, statins have multiple beneficial influences on vascular endothelial function, atherosclerotic plaque stability, inflammation, and thrombosis. These favorable pleiotropic effects may be the basis for their perioperative risk reduction in cardiothoracic and vascular procedures. The published evidence suggests that statins offer significant outcome benefits throughout perioperative practice. Because statin therapy significantly reduces the perioperative risk for patients undergoing cardiovascular procedures, they already are recommended in published guidelines. Beyond cardiac risk reduction, statin therapy also may protect the brain and the kidney in the perioperative setting, both in cardiac and vascular surgery. The pleiotropic effects of statins also appear to have therapeutic roles in the progression of valve disease, sepsis, and venous thrombosis. Further trials are required to provide data to drive their safe and comprehensive perioperative application for optimal patient outcome both in the short term and the long term. Because there are multiple randomized trials currently in progress throughout perioperative medicine, it is very likely that the indications for statins will be expanded significantly.
There have been major advances in perioperative cardiothoracic and vascular medicine. Because of ... more There have been major advances in perioperative cardiothoracic and vascular medicine. Because of promising data, steroids, statins, and endothelin antagonists are being clinically tested in randomized trials with adult cardiac surgical patients. In vascular surgical patients, recent meta-analysis has revealed that interventions such as -blockade or endovascular stenting for peripheral vascular lesions may not improve outcome overall. Furthermore, a landmark trial has shown that anesthetic technique does not affect outcome after carotid endarterectomy. The surgical Apgar score may become part of routine clinical care of the vascular surgical patient because it predicts outcome and can be calculated at the bedside. Recent studies confirm that the serious perioperative risks of hyperglycemia also apply to nondiabetic and pediatric cardiac surgical patients. This has been highlighted in the new guidelines from the Society of Thoracic Sur-geons. Perioperative myocardial protection is possible with ischemic preconditioning and omega-3 fatty acids. Pneumonia after lung resection may be reduced significantly by broadening antibiotic prophylaxis. Transfusion-related acute lung injury has immediate and delayed presentations that highlight the dangers of blood transfusion. Perioperative renal dysfunction after adult cardiac surgery is significantly reduced by the infusion of sodium bicarbonate. Although promising, further trials are required. Taken together, these recent advances will have significant influence on the future practice of cardiovascular and thoracic anesthesia as the ongoing search for perioperative outcome improvement achieves results.
Journal of cardiothoracic and vascular anesthesia, 2012
There have been rapid advances in oral anticoagulation. The oral factor Xa inhibitors rivaroxaban... more There have been rapid advances in oral anticoagulation. The oral factor Xa inhibitors rivaroxaban and apixaban and the oral direct thrombin inhibitor dabigatran recently have been rigorously evaluated. These novel anticoagulants will usher in a new paradigm for perioperative anticoagulation. Perioperative blood conservation in cardiac surgery recently has been highlighted in the updated guidelines by the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. These recommendations reflect a comprehensive evaluation of the recent evidence to optimize transfusion practice. Transcatheter mitral valve repair continues to mature. Transcatheter aortic valve implantation for aortic stenosis has entered the clinical mainstream, with randomized trials showing its superiority over medical management and its equivalency to surgical valve replacement in high-risk patients. This transformational technology represents a major leadership opportunity for the cardiac anesth...
Journal of cardiothoracic and vascular anesthesia, 2013
The considerable progress in P2Y12-platelet blockers has important perioperative implications due... more The considerable progress in P2Y12-platelet blockers has important perioperative implications due to a family of novel agents beyond clopidogrel. Although prasugrel is more potent than clopidogrel due to more efficient hepatic metabolism, it is limited clinically by its irreversibility and bleeding risks. Ticagrelor, as the first approved direct and reversible oral P2Y12 blocker, still is limited clinically by its novel side-effect profile. Intravenous reversible P2Y12 blockade is possible now with both cangrelor and elinogrel, although both agents are still in clinical development. Furthermore, elinogrel offers the possibility of both oral and parenteral P2Y12 blockade with a single agent. Future trials likely will continue to evaluate and compare the safety and efficacy of these agents in multiple clinical settings, including the perioperative period.
Journal of cardiothoracic and vascular anesthesia, 2014
This article reviewed selected research highlights of 2013 that pertain to the specialty of cardi... more This article reviewed selected research highlights of 2013 that pertain to the specialty of cardiothoracic and vascular anesthesia. The first major theme is the commemoration of the sixtieth anniversary of the first successful cardiac surgical procedure with cardiopulmonary bypass conducted by Dr Gibbon. This major milestone revolutionized the practice of cardiovascular surgery and invigorated a paradigm of mechanical platforms for contemporary perioperative cardiovascular practice. Dr Kolff was also a leading contributor in this area because of his important contributions to the refinement of cardiopulmonary bypass and mechanical ventricular assistance. The second major theme is the diffusion of echocardiography throughout perioperative practice. There are now guidelines and training pathways to guide its generalization into everyday practice. The third major theme is the paradigm shift in perioperative fluid management. Recent large randomized trials suggest that fluids are drugs ...
Journal of cardiothoracic and vascular anesthesia, 2014
There is currently a paradigm shift in the conduct of adult aortic arch repair. Although deep hyp... more There is currently a paradigm shift in the conduct of adult aortic arch repair. Although deep hypothermic circulatory arrest has been the classic perfusion platform for adult aortic arch repair, recent developments have challenged this aortic arch paradigm. There has been a gradual clinical drift towards moderate, and even mild, hypothermic circulatory arrest combined with antegrade cerebral perfusion. This paradigm shift appears to be associated with equivalent clinical outcomes, and in certain settings, with improved outcomes. The advent of endovascular therapy has challenged even further the concept that circulatory arrest is required for adult aortic arch repair. These dramatic advances have resulted in the emergence of an international aortic arch surgery study group that aims to advance this dynamic field through consensus statements, meta-analysis, clinical database analysis, prospective registries, and randomized controlled trials.
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, Jan 20, 2014
The care pathway for patients undergoing transcatheter aortic valve replacement (TAVR), particula... more The care pathway for patients undergoing transcatheter aortic valve replacement (TAVR), particularly in the US, was initially based on open surgical techniques and often includes general anesthesia, transesophageal echocardiographic monitoring, and cardiothoracic intensive care unit (ICU) stays. Whether a subgroup of patients could benefit from early extubation, fewer days in the ICU, and early ambulation in terms of both cost and effectiveness is unknown. A fast track (FT) protocol was initiated at two institutions in our health system with specific inclusion criteria. Patients with complications or morbidity post procedure deemed ineligible to continue on the FT pathway were designated as deviations. Baseline characteristics, success and deviations, subsequent course, and direct costs were compared for FT eligible and ineligible patients over a 6-month study period. Among 99 patients undergoing Transfemoral TAVR, 39 (39%) met FT inclusion criteria. The mean age of eligible and ine...
Journal of cardiothoracic and vascular anesthesia, 2015
Patients with an abdominal aortic aneurysm (AAA) could benefit from earlier diagnosis to improve ... more Patients with an abdominal aortic aneurysm (AAA) could benefit from earlier diagnosis to improve long-term outcomes. Candidate serum biomarkers for earlier AAA diagnosis include D-dimer, fibrinogen, low-density lipoprotein, high-density lipoprotein, lipoprotein(a), and the proteolytic enzymes known as matrix metalloproteinases. Furthermore, biomarkers such as brain natriuretic peptide significantly stratify perioperative risk in AAA repair. Statins significantly improve outcomes after AAA repair. They may also significantly slow AAA growth to allow pharmacologic arrest of AAA development. Recent trials have focused attention on fluid management for AAA repair. Although restrictive fluid management may significantly improve clinical outcomes, current evidence does not clearly support crystalloid or colloid for AAA repair. There may be an increased risk of renal dysfunction associated with hetastarch therapy. Endovascular repair has revolutionized the clinical management of AAAs. Recent trials have shown its significant outcome advantages. Furthermore, it is also applicable in high-risk operative cohorts and, in the future, may be suited for earlier AAA repair. This technology continues to advance with the development of branched and fenestrated grafts as well as total percutaneous endovascular AAA repair. Regardless of these advances, the clinical management of endoleaks will remain a major clinical focus. Taken together, these advances in the management of AAAs likely will significantly influence future clinical approaches to this challenging patient cohort.
Journal of cardiothoracic and vascular anesthesia, Jan 5, 2015
The first decade of clinical experience with transcatheter aortic valve replacement since 2002 sa... more The first decade of clinical experience with transcatheter aortic valve replacement since 2002 saw the development of 2 main valve systems, namely the Edwards Sapien balloon-expandable valve series and the Medtronic self-expanding CoreValve. These 2 valve platforms now have achieved commercial approval and application worldwide in patients with severe aortic stenosis whose perioperative risk for surgical intervention is high or extreme. In the second decade of transcatheter aortic valve replacement, clinical experience and refinements in valve design have resulted in clinical drift towards lower patient risk cohorts. There are currently 2 major trials, PARTNER II and SURTAVI, that are both evaluating the role of transcatheter aortic valve replacement in intermediate-risk patient cohorts. The results from these landmark trials may usher in a new clinical paradigm for transcatheter aortic valve replacement in its second decade.
Tennessee medicine : journal of the Tennessee Medical Association, 2003
Topical and local anesthetics are employed during minor invasive procedures to increase patient t... more Topical and local anesthetics are employed during minor invasive procedures to increase patient tolerance and to reduce the need for intravenous sedation. A potentially fatal complication of these anesthetics is methemoglobinemia (Met-Hgb). Met-Hgb should be suspected in patients with cyanosis that does not respond to administration of oxygen and who have a discrepancy in oxygen saturation measured by pulse oximetry compared with the arterial partial pressure of oxygen (PaO2) determined by blood gas analysis. We present a patient who developed life-threatening Met-Hgb from the local anesthesia required during percutaneous endoscopic gastrostomy tube placement.
Gallbladder cancer is found in about 1-2% of patients after laparoscopic cholecystectomy and it i... more Gallbladder cancer is found in about 1-2% of patients after laparoscopic cholecystectomy and it is difficult to diagnose preoperatively. Laparoscopic cholecystectomy may disseminate gallbladder cancer to peritoneum and even port sites. Here, we present a case of a 59-year-old female patient operated for gallstone disease and her histopathology was suggestive of well-diffentiated gallbladder carcinoma (T1N0M0). Patient presented to us with port site and distant peritoneal metastases after 3 months.
International journal of preventive medicine, 2014
India shares the largest burden of under-nutrition in world. The aim of this study was to conduct... more India shares the largest burden of under-nutrition in world. The aim of this study was to conduct follow-up assessment of under-nourished children attending anganwadi center (AWC). This was a retrospective cohort study conducted in 50 AWC of Tapi district. Total 529 children aged 1-6 years diagnosed as under-nourished before 1 year were included. Pre-structured questionnaire was used for present day assessment of these children followed by Epi-info mediated analysis. Children of literate mothers had higher weight gain. Ninety percent of children attended anganwadi regularly, however 25% of children dropped out for more than 1 month. In 1 year, growth had faltered in 20% children and was stagnant in 63% of them. Children who were treated for under-nutrition; that completed course at Child Development and Nutrition Center; and whose parents were counseled about the under-nourished status of child had higher weight gain than their counterparts. Parents of under-nourished children must ...
Journal of Structural and Functional Genomics, 2010
The Scottish Structural Proteomics Facility was funded to develop a laboratory scale approach to ... more The Scottish Structural Proteomics Facility was funded to develop a laboratory scale approach to high throughput structure determination. The effort was successful in that over 40 structures were determined. These structures and the methods harnessed to obtain them are reported here. This report reflects on the value of automation but also on the continued requirement for a high degree of scientific and technical expertise. The efficiency of the process poses challenges to the current paradigm of structural analysis and publication. In the 5 year period we published ten peer-reviewed papers reporting structural data arising from the pipeline. Nevertheless, the number of structures solved exceeded our ability to analyse and publish each new finding. By reporting the experimental details and depositing the structures we hope to maximize the impact of the project by allowing others to follow up the relevant biology.
Downy mildew (Peronospora plantaginis) caused two different types of infection in the floral part... more Downy mildew (Peronospora plantaginis) caused two different types of infection in the floral parts of isabgol (Plantago ovata). Systemic infection resulted in long spikes bearing weak and sterile florets, which later turned black due to saprophytic growth. Localised infection produced various symptoms ranging between normal flower opening and failure to bloom. Different parts of infected flowers such as sepal, petal, filament and anther were reduced in size compared to healthy flowers. However, gynoecium was elongated in localised infection. P. plantaginis induced gradual sterility of isabgol flowers. Androecium was affected more than the gynoecium was. Pollen number, pollen viability and germination reduced drastically due to localised infection. On the contrary, there were no significant differences between healthy and locally infected flowers in terms of stigma receptivity. In systemically infected spikes, bud development was arrested leading to sterility. When localised disease severity was high, secondary systemic infection caused similar symptoms. Microscopic observations showed presence of the pathogen in different parts of the flowers. Downy mildew adversely affected seed yield and quality; producing seeds, which were smaller and lighter than the healthy ones and later, became black. Seed yield was reduced by as much as 73.45 percent. Husk content per unit seed mass increased relatively as the total surface area of infected seeds increased.
Under iron limitation, the Gram-positive bacterium Streptomyces coelicolor A3(2) excretes three s... more Under iron limitation, the Gram-positive bacterium Streptomyces coelicolor A3(2) excretes three siderophores of the hydroxamate type: desferrioxamine B, desferrioxamine E, and coelichelin. These sequester iron from insoluble ferric hydroxides, and the resulting ferric complexes are believed to be transported into the cell via siderophore-binding proteins (SBPs) associated with ATP-binding cassette (ABC) transporters. Previous studies indicated that some of the genes in the desferrioxamine (des) and coelichelin (cch) biosynthetic clusters encode ABC transporter components required for efficient uptake of ferrioxamine E and ferricoelichelin, respectively, and a third ABC transporter gene cluster (cdt), not associated with siderophore biosynthesis genes, was implicated in the import of ferrioxamine B. In this study, the putative SBPs associated with these three gene clusters, DesE, CchF, and CdtB, were recombinantly overproduced in Escherichia coli and purified to homogeneity, and their binding affinity for cognate siderophores and noncognate siderophores was examined using fluorescence and circular dichroism spectroscopy. DesE was found to bind all of the ferric-tris-hydroxamates tested except ferricoelichelin, while CchF was found to bind only ferricoelichelin efficiently, providing further evidence that the cch cluster is a complete siderophore biosynthesis-export-uptake gene cluster. The picture was more complicated for CdtB, because it was found to be unstable in solution but was found to bind both ferrioxamine B and ferricoelichelin with high affinity. This was surprising because the cch cluster was previously reported to be necessary for efficient ferricoelichelin uptake. The remarkable specificity of the DesE and CchF proteins for different ferric-tris-hydroxamates raises intriguing questions about the molecular basis of their substrate specificity.
Patients with an abdominal aortic aneurysm (AAA) could benefit from earlier diagnosis to improve ... more Patients with an abdominal aortic aneurysm (AAA) could benefit from earlier diagnosis to improve long-term outcomes. Candidate serum biomarkers for earlier AAA diagnosis include D-dimer, fibrinogen, low-density lipoprotein, high-density lipoprotein, lipoprotein(a), and the proteolytic enzymes known as matrix metalloproteinases. Furthermore, biomarkers such as brain natriuretic peptide significantly stratify perioperative risk in AAA repair. Statins significantly improve outcomes after AAA repair. They may also significantly slow AAA growth to allow pharmacologic arrest of AAA development. Recent trials have focused attention on fluid management for AAA repair. Although restrictive fluid management may significantly improve clinical outcomes, current evidence does not clearly support crystalloid or colloid for AAA repair. There may be an increased risk of renal dysfunction associated with hetastarch therapy. Endovascular repair has revolutionized the clinical management of AAAs. Recent trials have shown its significant outcome advantages. Furthermore, it is also applicable in high-risk operative cohorts and, in the future, may be suited for earlier AAA repair. This technology continues to advance with the development of branched and fenestrated grafts as well as total percutaneous endovascular AAA repair. Regardless of these advances, the clinical management of endoleaks will remain a major clinical focus. Taken together, these advances in the management of AAAs likely will significantly influence future clinical approaches to this challenging patient cohort.
Beyond cholesterol reduction, statins have multiple beneficial influences on vascular endothelial... more Beyond cholesterol reduction, statins have multiple beneficial influences on vascular endothelial function, atherosclerotic plaque stability, inflammation, and thrombosis. These favorable pleiotropic effects may be the basis for their perioperative risk reduction in cardiothoracic and vascular procedures. The published evidence suggests that statins offer significant outcome benefits throughout perioperative practice. Because statin therapy significantly reduces the perioperative risk for patients undergoing cardiovascular procedures, they already are recommended in published guidelines. Beyond cardiac risk reduction, statin therapy also may protect the brain and the kidney in the perioperative setting, both in cardiac and vascular surgery. The pleiotropic effects of statins also appear to have therapeutic roles in the progression of valve disease, sepsis, and venous thrombosis. Further trials are required to provide data to drive their safe and comprehensive perioperative application for optimal patient outcome both in the short term and the long term. Because there are multiple randomized trials currently in progress throughout perioperative medicine, it is very likely that the indications for statins will be expanded significantly.
There have been major advances in perioperative cardiothoracic and vascular medicine. Because of ... more There have been major advances in perioperative cardiothoracic and vascular medicine. Because of promising data, steroids, statins, and endothelin antagonists are being clinically tested in randomized trials with adult cardiac surgical patients. In vascular surgical patients, recent meta-analysis has revealed that interventions such as -blockade or endovascular stenting for peripheral vascular lesions may not improve outcome overall. Furthermore, a landmark trial has shown that anesthetic technique does not affect outcome after carotid endarterectomy. The surgical Apgar score may become part of routine clinical care of the vascular surgical patient because it predicts outcome and can be calculated at the bedside. Recent studies confirm that the serious perioperative risks of hyperglycemia also apply to nondiabetic and pediatric cardiac surgical patients. This has been highlighted in the new guidelines from the Society of Thoracic Sur-geons. Perioperative myocardial protection is possible with ischemic preconditioning and omega-3 fatty acids. Pneumonia after lung resection may be reduced significantly by broadening antibiotic prophylaxis. Transfusion-related acute lung injury has immediate and delayed presentations that highlight the dangers of blood transfusion. Perioperative renal dysfunction after adult cardiac surgery is significantly reduced by the infusion of sodium bicarbonate. Although promising, further trials are required. Taken together, these recent advances will have significant influence on the future practice of cardiovascular and thoracic anesthesia as the ongoing search for perioperative outcome improvement achieves results.
Journal of cardiothoracic and vascular anesthesia, 2012
There have been rapid advances in oral anticoagulation. The oral factor Xa inhibitors rivaroxaban... more There have been rapid advances in oral anticoagulation. The oral factor Xa inhibitors rivaroxaban and apixaban and the oral direct thrombin inhibitor dabigatran recently have been rigorously evaluated. These novel anticoagulants will usher in a new paradigm for perioperative anticoagulation. Perioperative blood conservation in cardiac surgery recently has been highlighted in the updated guidelines by the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. These recommendations reflect a comprehensive evaluation of the recent evidence to optimize transfusion practice. Transcatheter mitral valve repair continues to mature. Transcatheter aortic valve implantation for aortic stenosis has entered the clinical mainstream, with randomized trials showing its superiority over medical management and its equivalency to surgical valve replacement in high-risk patients. This transformational technology represents a major leadership opportunity for the cardiac anesth...
Journal of cardiothoracic and vascular anesthesia, 2013
The considerable progress in P2Y12-platelet blockers has important perioperative implications due... more The considerable progress in P2Y12-platelet blockers has important perioperative implications due to a family of novel agents beyond clopidogrel. Although prasugrel is more potent than clopidogrel due to more efficient hepatic metabolism, it is limited clinically by its irreversibility and bleeding risks. Ticagrelor, as the first approved direct and reversible oral P2Y12 blocker, still is limited clinically by its novel side-effect profile. Intravenous reversible P2Y12 blockade is possible now with both cangrelor and elinogrel, although both agents are still in clinical development. Furthermore, elinogrel offers the possibility of both oral and parenteral P2Y12 blockade with a single agent. Future trials likely will continue to evaluate and compare the safety and efficacy of these agents in multiple clinical settings, including the perioperative period.
Journal of cardiothoracic and vascular anesthesia, 2014
This article reviewed selected research highlights of 2013 that pertain to the specialty of cardi... more This article reviewed selected research highlights of 2013 that pertain to the specialty of cardiothoracic and vascular anesthesia. The first major theme is the commemoration of the sixtieth anniversary of the first successful cardiac surgical procedure with cardiopulmonary bypass conducted by Dr Gibbon. This major milestone revolutionized the practice of cardiovascular surgery and invigorated a paradigm of mechanical platforms for contemporary perioperative cardiovascular practice. Dr Kolff was also a leading contributor in this area because of his important contributions to the refinement of cardiopulmonary bypass and mechanical ventricular assistance. The second major theme is the diffusion of echocardiography throughout perioperative practice. There are now guidelines and training pathways to guide its generalization into everyday practice. The third major theme is the paradigm shift in perioperative fluid management. Recent large randomized trials suggest that fluids are drugs ...
Journal of cardiothoracic and vascular anesthesia, 2014
There is currently a paradigm shift in the conduct of adult aortic arch repair. Although deep hyp... more There is currently a paradigm shift in the conduct of adult aortic arch repair. Although deep hypothermic circulatory arrest has been the classic perfusion platform for adult aortic arch repair, recent developments have challenged this aortic arch paradigm. There has been a gradual clinical drift towards moderate, and even mild, hypothermic circulatory arrest combined with antegrade cerebral perfusion. This paradigm shift appears to be associated with equivalent clinical outcomes, and in certain settings, with improved outcomes. The advent of endovascular therapy has challenged even further the concept that circulatory arrest is required for adult aortic arch repair. These dramatic advances have resulted in the emergence of an international aortic arch surgery study group that aims to advance this dynamic field through consensus statements, meta-analysis, clinical database analysis, prospective registries, and randomized controlled trials.
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, Jan 20, 2014
The care pathway for patients undergoing transcatheter aortic valve replacement (TAVR), particula... more The care pathway for patients undergoing transcatheter aortic valve replacement (TAVR), particularly in the US, was initially based on open surgical techniques and often includes general anesthesia, transesophageal echocardiographic monitoring, and cardiothoracic intensive care unit (ICU) stays. Whether a subgroup of patients could benefit from early extubation, fewer days in the ICU, and early ambulation in terms of both cost and effectiveness is unknown. A fast track (FT) protocol was initiated at two institutions in our health system with specific inclusion criteria. Patients with complications or morbidity post procedure deemed ineligible to continue on the FT pathway were designated as deviations. Baseline characteristics, success and deviations, subsequent course, and direct costs were compared for FT eligible and ineligible patients over a 6-month study period. Among 99 patients undergoing Transfemoral TAVR, 39 (39%) met FT inclusion criteria. The mean age of eligible and ine...
Journal of cardiothoracic and vascular anesthesia, 2015
Patients with an abdominal aortic aneurysm (AAA) could benefit from earlier diagnosis to improve ... more Patients with an abdominal aortic aneurysm (AAA) could benefit from earlier diagnosis to improve long-term outcomes. Candidate serum biomarkers for earlier AAA diagnosis include D-dimer, fibrinogen, low-density lipoprotein, high-density lipoprotein, lipoprotein(a), and the proteolytic enzymes known as matrix metalloproteinases. Furthermore, biomarkers such as brain natriuretic peptide significantly stratify perioperative risk in AAA repair. Statins significantly improve outcomes after AAA repair. They may also significantly slow AAA growth to allow pharmacologic arrest of AAA development. Recent trials have focused attention on fluid management for AAA repair. Although restrictive fluid management may significantly improve clinical outcomes, current evidence does not clearly support crystalloid or colloid for AAA repair. There may be an increased risk of renal dysfunction associated with hetastarch therapy. Endovascular repair has revolutionized the clinical management of AAAs. Recent trials have shown its significant outcome advantages. Furthermore, it is also applicable in high-risk operative cohorts and, in the future, may be suited for earlier AAA repair. This technology continues to advance with the development of branched and fenestrated grafts as well as total percutaneous endovascular AAA repair. Regardless of these advances, the clinical management of endoleaks will remain a major clinical focus. Taken together, these advances in the management of AAAs likely will significantly influence future clinical approaches to this challenging patient cohort.
Journal of cardiothoracic and vascular anesthesia, Jan 5, 2015
The first decade of clinical experience with transcatheter aortic valve replacement since 2002 sa... more The first decade of clinical experience with transcatheter aortic valve replacement since 2002 saw the development of 2 main valve systems, namely the Edwards Sapien balloon-expandable valve series and the Medtronic self-expanding CoreValve. These 2 valve platforms now have achieved commercial approval and application worldwide in patients with severe aortic stenosis whose perioperative risk for surgical intervention is high or extreme. In the second decade of transcatheter aortic valve replacement, clinical experience and refinements in valve design have resulted in clinical drift towards lower patient risk cohorts. There are currently 2 major trials, PARTNER II and SURTAVI, that are both evaluating the role of transcatheter aortic valve replacement in intermediate-risk patient cohorts. The results from these landmark trials may usher in a new clinical paradigm for transcatheter aortic valve replacement in its second decade.
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Papers by Prakash Patel