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Our automated deep learning-based approach identifies consolidation/collapse in LUS images to aid in the identification of late stages of COVID-19 induced pneumonia, where consolidation/collapse is one of the possible associated pathologies. A common challenge in training such models is that annotating each frame of an ultrasound video requires high labelling effort. This effort in practice becomes prohibitive for large ultrasound datasets. To understand the impact of various degrees of labelling precision, we compare labelling strategies to train fully supervised models (frame-based method, higher labelling effort) and inaccurately supervised models (video-based methods, lower labelling effort), both of which yield binary predictions for LUS videos on a frame-by-frame level. We moreover introduce a novel sampled quaternary method which randomly samples only 10% of the LUS video frames and subsequently assigns (ordinal) categorical labels to all frames in the video based on the fraction of positively annotated samples. This method outperformed the inaccurately supervised video-based method and more surprisingly, the supervised frame-based approach with respect to metrics such as precision-recall area under curve (PR-AUC) and F1 score, despite being a form of inaccurate learning. We argue that our video-based method is more robust with respect to label noise and mitigates overfitting in a manner similar to label smoothing. The algorithm was trained using a ten-fold cross validation, which resulted in a PR-AUC score of 73% and an accuracy of 89%. While the efficacy of our classifier using the sampled quaternary method significantly lowers the labelling effort, it must be verified on a larger consolidation/collapse dataset, our proposed classifier using the sampled quaternary video-based method is clinically comparable with trained experts' performance.

BACKGROUND: Transfusion Requirements in Cardiac Surgery III (TRICS III), a multi-center randomized controlled trial, demonstrated clinical non-inferiority for restrictive versus liberal RBC transfusion for patients undergoing cardiac surgery. However, it is uncertain if transfusion strategy affects long-term health-related quality of life (HRQOL). STUDY DESIGN AND METHODS: In this planned sub-study of Australian patients in TRICS III, we sought to determine the non-inferiority of restrictive versus liberal transfusion strategy on long-term HRQOL and to describe clinical outcomes 24 months postoperatively. The restrictive strategy involved transfusing RBCs when hemoglobin was <7.5 g/dl; the transfusion triggers in the liberal group were: <9.5 g/L intraoperatively, <9.5 g/L in intensive care, or <8.5 g/dl on the ward. HRQOL assessments were performed using the 36-item short form survey version 2 (SF-36v2). Primary outcome was non-inferiority of summary measures of SF-36v2 at 12 months, (non-inferiority margin: -0.25 effect size; restrictive minus liberal scores). Secondary outcomes included non-inferiority of HRQOL at 18 and 24 months. RESULTS: Six hundred seventeen Australian patients received allocated randomization; HRQOL data were available for 208/311 in restrictive and 217/306 in liberal group. After multiple imputation, non-inferiority of restrictive transfusion at 12 months was not demonstrated for HRQOL, and the estimates were directionally in favor of liberal transfusion. Non-inferiority also could not be concluded at 18 and 24 months. Sensitivity analyses supported these results. There were no differences in quality-adjusted life years or composite clinical outcomes up to 24 months after surgery. DISCUSSION: The non-inferiority of a restrictive compared to a liberal transfusion strategy was not established for long-term HRQOL in this dataset.

The aim in this systematic review was to determine the effect of point-of-care ultrasound (POCUS) on the clinical decision-making process and patient outcomes in adults admitted to the general medicine ward. A comprehensive search was performed in MEDLINE (Ovid), EMBASE (Ovid), PubMed, the Cochrane Library, ClinicalTrials.gov, Scopus, LILACS and Cinahl. Articles had to fulfill the inclusion criteria of randomised or non-randomised studies assessing the impact of POCUS on the diagnosis, management, length of hospital stay or mortality of patients admitted to the internal medicine ward. Six studies were included involving a total of 1836 patients. The influence of POCUS on the diagnosis was reported as a change in the main diagnosis or the addition of a relevant diagnosis in up to 18% and 24% of the cases, respectively. Impact on the management plan was reported in 37% to 52.1% of the participants. Three studies documented the impact of POCUS on the length of stay. Two of them reported no difference between groups, and the other reported a significant reduction of 1 d of the hospital stay. In conclusion, POCUS appears to have positive effects on the clinical decision-making process with impacts on optimal patient management and possible reduction in the hospital length of stay.Copyright © 2021 World Federation for Ultrasound in Medicine & Biology

The aim in this systematic review was to determine the effect of point-of-care ultrasound (POCUS) on the clinical decision-making process and patient outcomes in adults admitted to the general medicine ward. A comprehensive search was performed in MEDLINE (Ovid), EMBASE (Ovid), PubMed, the Cochrane Library, ClinicalTrials.gov, Scopus, LILACS and Cinahl. Articles had to fulfill the inclusion criteria of randomised or non-randomised studies assessing the impact of POCUS on the diagnosis, management, length of hospital stay or mortality of patients admitted to the internal medicine ward. Six studies were included involving a total of 1836 patients. The influence of POCUS on the diagnosis was reported as a change in the main diagnosis or the addition of a relevant diagnosis in up to 18% and 24% of the cases, respectively. Impact on the management plan was reported in 37% to 52.1% of the participants. Three studies documented the impact of POCUS on the length of stay. Two of them reported no difference between groups, and the other reported a significant reduction of 1 d of the hospital stay. In conclusion, POCUS appears to have positive effects on the clinical decision-making process with impacts on optimal patient management and possible reduction in the hospital length of stay.Copyright © 2021 World Federation for Ultrasound in Medicine & Biology

BACKGROUND: The Postoperative Quality of Recovery Scale (PostopQRS) is a survey-based tool that measures quality of the postoperative recovery in multiple domains over multiple time periods. The purpose of this study is to validate the Japanese version of the PostopQRS. METHODS: A prospective observational study using bilingual healthy volunteers was conducted in Australia to assess equivalence of the test values between the two languages. To assess the feasibility and discriminant validity of the PostopQRS in a Japanese population, an observational study was conducted on patients undergoing ear-nose-throat and orthopedic surgery in Japan, with measurements performed prior to surgery, 2 h, and 1, 3, and 7 days following surgery. The survey was conducted face-to-face while in hospital and via the telephone following discharge. RESULTS: Sixty-eight volunteers participated in the validation study. The scores in the Japanese version were similar to the English version in all domains at all timepoints. In the cognitive domain, there were no differences between the Japanese and English versions for word recall and word generation tasks. For digits forwards and digits backwards the values were skewed to the maximal value, and although significantly different, the absolute difference was <10% at all timepoints between English and Japanese versions. Fifty-one patients, ear-nose-throat (n=22) and orthopedic (n=29), were included in the clinical study. Orthopedic patients had a significantly worse recovery profile over time in overall recovery (p<0.01), physiological (p=0.02), nociceptive (p=0.03), and activities of daily living (ADL, p<0.01) domains, but was not different for emotive (p=0.30) or cognitive domains (p=0.10). CONCLUSION: The Japanese version of the PostopQRS is similar to the English version and was able to discriminate recovery between different surgery disciplines. TRIAL REGISTRATION: UMIN, UMIN000033268 , Registered 6 August 2018.

AIM: To characterize the association between diabetes and transfusion and clinical outcomes in cardiac surgery, and to evaluate whether restrictive transfusion thresholds are harmful in these patients. MATERIALS AND METHODS: The multinational, open-label, randomized controlled TRICS-III trial assessed a restrictive transfusion strategy (haemoglobin [Hb] transfusion threshold <75 g/L) compared with a liberal strategy (Hb <95 g/L for operating room or intensive care unit; or <85 g/L for ward) in patients undergoing cardiac surgery on cardiopulmonary bypass with a moderate-to-high risk of death (EuroSCORE ≥6). Diabetes status was collected preoperatively. The primary composite outcome was all-cause death, stroke, myocardial infarction, and new-onset renal failure requiring dialysis at 6 months. Secondary outcomes included components of the composite outcome at 6 months, and transfusion and clinical outcomes at 28 days. RESULTS: Of the 5092 patients analysed, 1396 (27.4%) had diabetes (restrictive, n = 679; liberal, n = 717). Patients with diabetes had more cardiovascular disease than patients without diabetes. Neither the presence of diabetes (OR [95% CI] 1.10 [0.93-1.31]) nor the restrictive strategy increased the risk for the primary composite outcome (diabetes OR [95% CI] 1.04 [0.68-1.59] vs. no diabetes OR 1.02 [0.85-1.22]; Pinteraction = .92). In patients with versus without diabetes, a restrictive transfusion strategy was more effective at reducing red blood cell transfusion (diabetes OR [95% CI] 0.28 [0.21-0.36]; no diabetes OR [95% CI] 0.40 [0.35-0.47]; Pinteraction = .04). CONCLUSIONS: The presence of diabetes did not modify the effect of a restrictive transfusion strategy on the primary composite outcome, but improved its efficacy on red cell transfusion. Restrictive transfusion triggers are safe and effective in patients with diabetes undergoing cardiac surgery.

PURPOSE: To establish the test-retest and inter-rater reliability of lumbar multifidus (LM) and iliocostalis lumborum (IL) muscle thickness and echogenicity as derived using ultrasound imaging. METHODS: Ultrasound images of the LM and IL were collected from 11 healthy participants on two occasions, 1 week apart, by two independent assessors. Measures of LM and IL thickness and echogenicity were subject to test-retest and inter-rater reliability, which was assessed by calculation of an F statistic, the interclass correlation coefficient (ICC), the standard error of measurement, 95% confidence intervals and Bland-Altman plots. This study was given approval by The University of Melbourne Behavioural and Social Sciences Human Ethics Sub-Committee (ref: 1749845). RESULTS: Assessors A and B showed good to excellent test-retest reliability for LM thickness (ICC3,3 A: 0.89 and B: 0.98), LM echogenicity (ICC3,3 A: 0.93 and B: 0.95) and IL echogenicity (ICC3,3 A: 0.87 and B: 0.83). Test-retest reliability for IL thickness was poor for Assessor A but excellent for Assessor B. Both assessors demonstrated excellent inter-rater reliability for LM thickness and echogenicity (ICC2,3: 0.79 and 0.94), but poor reliability for IL thickness and echogenicity (ICC2,3: 0.00 and 0.39). CONCLUSIONS: Inter-rater and test-retest reliability was excellent for LM but was less reliable for measures of the IL muscle.

Background: Fractured neck of femur (hip fracture) surgery is common and associated with high mortality and morbidity, principally due to prevalent heart disease that is often unrecognised and inadequately treated before surgery. Focused cardiac ultrasound (FCU) is a form of transthoracic echocardiography (TTE) used for non-invasive assessment of cardiac disease before surgery that frequently alters important perioperative cardiac diagnosis and management and may be associated with lower mortality(1). This pilot study aimed to assess feasibility, calibrate the primary composite outcome and determine group separation, prior to a multi-centre random control trial (RCT) (n=1900) of the impact of preoperative FCU on postoperative mortality and morbidity after hip fracture surgery. Method(s): Recruitment occurred between February 1 and December 21, 2016 at the Royal Melbourne Hospital, with other sites activated during the period (Western General Hospital, The Prince Charles Hospital and The Queen Elizabeth Hospital). Inclusion criteria included participants aged >18 years scheduled for unilateral repair of hip fracture. Exclusion criteria included additional or re-do surgery, known or suspected metastatic cancer or unlikely to survive>24 hours, or previous documented TTE within 30 days of admission. Participants were randomised to either receive (FCU group) or not (controls) before surgery. FCU was performed by independent operators proficient in FCU, and followed the iHeartScan protocol (University of Melbourne), which has been validated in the perioperative setting. The primary outcome was 30-day composite outcome of mortality, acute kidney injury, non-fatal myocardial infarction, stroke, pulmonary embolism and cardiac arrest. Secondary outcomes included impact of FCU on diagnosis and management by the anaesthetist and inpatient hospital costs. The feasibility aims included recruitment of >1 patient per week per site during active recruitment, a screening:recruitment

Background: Point-of-care ultrasound (POCUS) is emerging as a reliable and valid clinical tool that impacts diagnosis and clinical decision-making as well as timely intervention for optimal patient management. This makes its utility in patients admitted to internal medicine wards attractive. However, there is still an evidence gap in all the medical setting of how its use affects clinical variables such as length of stay, morbidity, and mortality. Methods/design: A prospective randomized controlled trial assessing the effect of a surface POCUS of the heart, lungs, and femoral and popliteal veins performed by an internal medicine physician during the first 24 h of patient admission to the unit with a presumptive cardiopulmonary diagnosis. The University of Melbourne iHeartScan, iLungScan, and two-point venous compression protocols are followed to identify left and right ventricular function, significant valvular heart disease, pericardial and pleural effusion, consolidation, pulmonary edema, pneumothorax, and proximal deep venous thrombosis. Patient management is not commanded by the protocol and is at the discretion of the treating team. A total of 250 patients will be recruited at one tertiary hospital. Participants are randomized to receive POCUS or no POCUS. The primary outcome measured will be hospital length of stay. Secondary outcomes include the change in diagnosis and management, 30-day hospital readmission, and healthcare costs. Discussion(s): This study will evaluate the clinical impact of multi-organ POCUS in internal medicine patients admitted with cardiopulmonary diagnosis on the hospital length of stay. Recruitment of participants commenced in September 2018 and is estimated to be completed by March 2020. Trial registration: Australian and New Zealand Clinical Trial Registry, ACTRN12618001442291. Registered on 28 August 2018.Copyright © 2020 The Author(s).

OBJECTIVE: The aim of this study was to investigate the psychometric properties of the shortened version of the Functional Difficulties Questionnaire (FDQ). DESIGN: This is a multisite observational study. SETTING: The study was conducted in four tertiary care hospitals in Australia. SUBJECTS: A total of 225 participants, following cardiac surgery, were involved in the study. INTERVENTION: Participants completed the original 13-item FDQ and other measures of physical function, pain and health-related quality of life. METHOD(S): Item reduction was utilized to develop the shortened version. Reliability was evaluated using intraclass correlation coefficients (ICCs), the smallest detectable change and Bland-Altman plots. The validity and responsiveness were evaluated using correlation. Anchor and distribution-based calculation was used to calculate the minimal clinical important difference (MCID). RESULT(S): Item reduction resulted in the creation of a 10-item shortened version of the questionnaire (FDQ-s). Within the cohort of cardiac surgery patient, the mean (SD) for the FDQ-s was 38.7 (19.61) at baseline; 15.5 (14.01) at four weeks and 7.9 (12.01) at threemonths. Validity: excellent internal consistency (Cronbach's alpha>0.90) and fair-to-excellent construct validity (>0.4). Reliability: internal consistency was excellent (Cronbach's alpha > 0.8). The FDQ-s had excellent test-retest reliability (ICC = 0.89-0.92). Strong responsiveness overtime was demonstrated with large effect sizes (Cohen's d>1.0). The MCID of the FDQ-s was calculated between 4 and 10 out of 100(in cm). CONCLUSION(S): The FDQ-s demonstrated robust psychometric properties as a measurement tool of physical function of the thoracic region following cardiac surgery.

The adoption of point-of-care lung ultrasound for both suspected and confirmed COVID-19 patients highlights the issues of accessibility to ultrasound training and equipment. Lung ultrasound is more sensitive than chest radiography in detecting viral pneumonitis and preferred over computed tomography for reasons including its portability, reduced healthcare worker exposure and repeatability. The main lung ultrasound findings in COVID-19 patients are interstitial syndrome, irregular pleural line and subpleural consolidations. Consolidations are most likely found in critical patients in need of ventilatory support. Hence, lung ultrasound may be used to timely triage patients who may have evolving pneumonitis. Other respiratory pathology that may be detected by lung ultrasound includes pulmonary oedema, pneumothorax, consolidation and large effusion. A key barrier to incorporate lung ultrasound in the assessment of COVID-19 patients is adequate decontamination of ultrasound equipment to avoid viral spread. This tutorial provides a practical method to learn lung ultrasound and a cost-effective method of preventing contamination of ultrasound equipment and a practical method for performing and interpreting lung ultrasound.Copyright © 2020 Australasian Society for Ultrasound in Medicine

Background: Fractured neck of femur (hip fracture) surgery is common and associated with high mortality and morbidity, principally due to prevalent heart disease that is often unrecognised and inadequately treated before surgery. Focused cardiac ultrasound (FCU) is a form of transthoracic echocardiography (TTE) used for non-invasive assessment of cardiac disease before surgery that frequently alters important perioperative cardiac diagnosis and management and may be associated with lower mortality(1). This pilot study aimed to assess feasibility, calibrate the primary composite outcome and determine group separation, prior to a multi-centre random control trial (RCT) (n=1900) of the impact of preoperative FCU on postoperative mortality and morbidity after hip fracture surgery. Method(s): Recruitment occurred between February 1 and December 21, 2016 at the Royal Melbourne Hospital, with other sites activated during the period (Western General Hospital, The Prince Charles Hospital and The Queen Elizabeth Hospital). Inclusion criteria included participants aged >18 years scheduled for unilateral repair of hip fracture. Exclusion criteria included additional or re-do surgery, known or suspected metastatic cancer or unlikely to survive>24 hours, or previous documented TTE within 30 days of admission. Participants were randomised to either receive (FCU group) or not (controls) before surgery. FCU was performed by independent operators proficient in FCU, and followed the iHeartScan protocol (University of Melbourne), which has been validated in the perioperative setting. The primary outcome was 30-day composite outcome of mortality, acute kidney injury, non-fatal myocardial infarction, stroke, pulmonary embolism and cardiac arrest. Secondary outcomes included impact of FCU on diagnosis and management by the anaesthetist and inpatient hospital costs. The feasibility aims included recruitment of >1 patient per week per site during active recruitment, a screening:recruitment

Pulmonary complications are the most common clinical manifestations of coronavirus disease (COVID-19). From recent clinical observation, two phenotypes have emerged: a low elastance or L-type and a high elastance or H-type. Clinical presentation, pathophysiology, pulmonary mechanics, radiological and ultrasound findings of these two phenotypes are different. Consequently, the therapeutic approach also varies between the two. We propose a management algorithm that combines the respiratory rate and oxygenation index with bedside lung ultrasound examination and monitoring that could help determine earlier the requirement for intubation and other surveillance of COVID-19 patients with respiratory failure.Copyright © 2020, Canadian Anesthesiologists' Society.

Background: Point-of-care ultrasound (POCUS) is emerging as a reliable and valid clinical tool that impacts diagnosis and clinical decision-making as well as timely intervention for optimal patient management. This makes its utility in patients admitted to internal medicine wards attractive. However, there is still an evidence gap in all the medical setting of how its use affects clinical variables such as length of stay, morbidity, and mortality. Methods/design: A prospective randomized controlled trial assessing the effect of a surface POCUS of the heart, lungs, and femoral and popliteal veins performed by an internal medicine physician during the first 24 h of patient admission to the unit with a presumptive cardiopulmonary diagnosis. The University of Melbourne iHeartScan, iLungScan, and two-point venous compression protocols are followed to identify left and right ventricular function, significant valvular heart disease, pericardial and pleural effusion, consolidation, pulmonary edema, pneumothorax, and proximal deep venous thrombosis. Patient management is not commanded by the protocol and is at the discretion of the treating team. A total of 250 patients will be recruited at one tertiary hospital. Participants are randomized to receive POCUS or no POCUS. The primary outcome measured will be hospital length of stay. Secondary outcomes include the change in diagnosis and management, 30-day hospital readmission, and healthcare costs. Discussion(s): This study will evaluate the clinical impact of multi-organ POCUS in internal medicine patients admitted with cardiopulmonary diagnosis on the hospital length of stay. Recruitment of participants commenced in September 2018 and is estimated to be completed by March 2020. Trial registration: Australian and New Zealand Clinical Trial Registry, ACTRN12618001442291. Registered on 28 August 2018.Copyright © 2020 The Author(s).

OBJECTIVE: The aim of this study was to investigate the psychometric properties of the shortened version of the Functional Difficulties Questionnaire (FDQ). DESIGN: This is a multisite observational study. SETTING: The study was conducted in four tertiary care hospitals in Australia. SUBJECTS: A total of 225 participants, following cardiac surgery, were involved in the study. INTERVENTION: Participants completed the original 13-item FDQ and other measures of physical function, pain and health-related quality of life. METHOD(S): Item reduction was utilized to develop the shortened version. Reliability was evaluated using intraclass correlation coefficients (ICCs), the smallest detectable change and Bland-Altman plots. The validity and responsiveness were evaluated using correlation. Anchor and distribution-based calculation was used to calculate the minimal clinical important difference (MCID). RESULT(S): Item reduction resulted in the creation of a 10-item shortened version of the questionnaire (FDQ-s). Within the cohort of cardiac surgery patient, the mean (SD) for the FDQ-s was 38.7 (19.61) at baseline; 15.5 (14.01) at four weeks and 7.9 (12.01) at threemonths. Validity: excellent internal consistency (Cronbach's alpha>0.90) and fair-to-excellent construct validity (>0.4). Reliability: internal consistency was excellent (Cronbach's alpha > 0.8). The FDQ-s had excellent test-retest reliability (ICC = 0.89-0.92). Strong responsiveness overtime was demonstrated with large effect sizes (Cohen's d>1.0). The MCID of the FDQ-s was calculated between 4 and 10 out of 100(in cm). CONCLUSION(S): The FDQ-s demonstrated robust psychometric properties as a measurement tool of physical function of the thoracic region following cardiac surgery.

The adoption of point-of-care lung ultrasound for both suspected and confirmed COVID-19 patients highlights the issues of accessibility to ultrasound training and equipment. Lung ultrasound is more sensitive than chest radiography in detecting viral pneumonitis and preferred over computed tomography for reasons including its portability, reduced healthcare worker exposure and repeatability. The main lung ultrasound findings in COVID-19 patients are interstitial syndrome, irregular pleural line and subpleural consolidations. Consolidations are most likely found in critical patients in need of ventilatory support. Hence, lung ultrasound may be used to timely triage patients who may have evolving pneumonitis. Other respiratory pathology that may be detected by lung ultrasound includes pulmonary oedema, pneumothorax, consolidation and large effusion. A key barrier to incorporate lung ultrasound in the assessment of COVID-19 patients is adequate decontamination of ultrasound equipment to avoid viral spread. This tutorial provides a practical method to learn lung ultrasound and a cost-effective method of preventing contamination of ultrasound equipment and a practical method for performing and interpreting lung ultrasound.Copyright © 2020 Australasian Society for Ultrasound in Medicine

BACKGROUND: Where each patient has all three conduits of internal mammary artery (IMA), saphenous vein graft (SVG) and radial artery (RA), most confounders affecting comparison between conduits can be mitigated. Additionally, since SVG progressively fails over time, restricting patient angiography to the late period only can mitigate against early SVG patency that may have occluded in the late period. METHODS: Research protocol driven conventional angiography was performed for patients with at least one of each conduit of IMA, RA and SVG and a minimum of 7 years postoperative. The primary analysis was perfect patency and secondary analysis was overall patency including angiographic evidence of conduit lumen irregularity from conduit atheroma. Multivariable generalized linear mixed model (GLMM) was used. Patency excluded occluded or "string sign" conduits. Perfect patency was present in patent grafts if there was no lumen irregularity. RESULTS: Fifty patients underwent coronary angiography at overall duration postoperative 13.1 ± 2.9, and age 74.3 ± 7.0 years. Of 196 anastomoses, IMA 62, RA 77 and SVG 57. Most IMA were to the left anterior descending territory and most RA and SVG were to the circumflex and right coronary territories. Perfect patency RA 92.2% was not different to IMA 96.8%, P = 0.309; and both were significantly better than SVG 17.5%, P < 0.001. Patency RA 93.5% was also not different to IMA 96.8%, P = 0.169, and both arterial conduits were significantly higher than SVG 82.5%, P = 0.029. Grafting according to coronary territory was not significant for perfect patency, P = 0.997 and patency P = 0.289. Coronary stenosis predicted perfect patency for RA only, P = 0.030 and for patency, RA, P = 0.007, and SVG, P = 0.032. When both arterial conduits were combined, perfect patency, P < 0.001, and patency, P = 0.017, were superior to SVG. CONCLUSIONS: All but one patent internal mammary artery or radial artery grafts had perfect patency and had superior perf

BACKGROUND: Point-of-care ultrasound (POCUS) is emerging as a reliable and valid clinical tool that impacts diagnosis and clinical decision-making as well as timely intervention for optimal patient management. This makes its utility in patients admitted to internal medicine wards attractive. However, there is still an evidence gap in all the medical setting of how its use affects clinical variables such as length of stay, morbidity, and mortality. METHODS/DESIGN: A prospective randomized controlled trial assessing the effect of a surface POCUS of the heart, lungs, and femoral and popliteal veins performed by an internal medicine physician during the first 24 h of patient admission to the unit with a presumptive cardiopulmonary diagnosis. The University of Melbourne iHeartScan, iLungScan, and two-point venous compression protocols are followed to identify left and right ventricular function, significant valvular heart disease, pericardial and pleural effusion, consolidation, pulmonary edema, pneumothorax, and proximal deep venous thrombosis. Patient management is not commanded by the protocol and is at the discretion of the treating team. A total of 250 patients will be recruited at one tertiary hospital. Participants are randomized to receive POCUS or no POCUS. The primary outcome measured will be hospital length of stay. Secondary outcomes include the change in diagnosis and management, 30-day hospital readmission, and healthcare costs. DISCUSSION: This study will evaluate the clinical impact of multi-organ POCUS in internal medicine patients admitted with cardiopulmonary diagnosis on the hospital length of stay. Recruitment of participants commenced in September 2018 and is estimated to be completed by March 2020. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry, ACTRN12618001442291. Registered on 28 August 2018.

Deep neuromuscular block aims to improve operative conditions during laparoscopic surgery with a lower intra-abdominal pressure. Studies are conflicting on whether meaningful improvements in quality of recovery occur beyond emergence, and whether lower intra-abdominal pressure is achieved. In this pragmatic randomised trial with 1:1 allocation, adults undergoing elective laparoscopic surgery were allocated to moderate neuromuscular block reversed with neostigmine, or deep neuromuscular block reversed with sugammadex. Allocation was revealed to the anaesthetist only. Primary outcome was cognitive recovery of the Postoperative Quality of Recovery Scale, 7 days after surgery. Secondary outcomes included recovery in other domains of the Postoperative Quality of Recovery Scale at 15 min and 40 min; days 1, 3, 7, 14; and 1 and 3 months after surgery. Chi-square test was used for the primary outcome, and generalised linear mixed model for recovery over time between groups. Of 350 participants randomised, 140 (deep) and 144 (moderate) were analysed for the primary outcome. There was no difference in the Postoperative Quality of Recovery Scale cognitive domain at day 7 (deep 92.9% vs. moderate 91.8%, OR 1.164; 95%CI 0.486-2.788, p = 0.826), or at any other time-point. No significant difference was observed for physiological, emotive, activities of daily living, nociception, or overall recovery. Length of stay in the recovery area (mean (SD) deep 108 (58) vs. moderate 109 (57) min, p = 0.78) and hospital (1.8 (1.9) vs. 2.6 (3.5) days, p = 0.019) was not different. Intra-abdominal pressure and surgical operating conditions were not different between groups. Deep neuromuscular block did not improve quality of recovery compared with moderate neuromuscular block in operative laparoscopic surgery over a 1-h duration.

Single internal mammary artery and supplementary saphenous vein grafts (SVG) continues to be used in approximately 95% of coronary surgery as of 2019. The late failure of SVG is very well documented yet remains the predominant conduit used - why? The left internal mammary artery almost never fails, and late angiography of patent radial artery grafts also appear entirely normal. Logic would suggest that avoiding the conduit known to progressively fail would lead to improved late outcome. Our studies have demonstrated such findings in large single centre and national registry datasets. We describe strategies to achievement of total arterial coronary revascularisation.

Pulmonary complications are the most common clinical manifestations of coronavirus disease (COVID-19). From recent clinical observation, two phenotypes have emerged: a low elastance or L-type and a high elastance or H-type. Clinical presentation, pathophysiology, pulmonary mechanics, radiological and ultrasound findings of these two phenotypes are different. Consequently, the therapeutic approach also varies between the two. We propose a management algorithm that combines the respiratory rate and oxygenation index with bedside lung ultrasound examination and monitoring that could help determine earlier the requirement for intubation and other surveillance of COVID-19 patients with respiratory failure.

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.

The adoption of point-of-care lung ultrasound for both suspected and confirmed COVID-19 patients highlights the issues of accessibility to ultrasound training and equipment. Lung ultrasound is more sensitive than chest radiography in detecting viral pneumonitis and preferred over computed tomography for reasons including its portability, reduced healthcare worker exposure and repeatability. The main lung ultrasound findings in COVID-19 patients are interstitial syndrome, irregular pleural line and subpleural consolidations. Consolidations are most likely found in critical patients in need of ventilatory support. Hence, lung ultrasound may be used to timely triage patients who may have evolving pneumonitis. Other respiratory pathology that may be detected by lung ultrasound includes pulmonary oedema, pneumothorax, consolidation and large effusion. A key barrier to incorporate lung ultrasound in the assessment of COVID-19 patients is adequate decontamination of ultrasound equipment to avoid viral spread. This tutorial provides a practical method to learn lung ultrasound and a cost-effective method of preventing contamination of ultrasound equipment and a practical method for performing and interpreting lung ultrasound.

Objective There is initial evidence that the use of volatile anesthetics can reduce the postoperative release of cardiac troponin I, the need for inotropic support, and the number of patients requiring prolonged hospitalization following coronary artery bypass graft (CABG) surgery. Nevertheless, small randomized controlled trials have failed to demonstrate a survival advantage. Thus, whether volatile anesthetics improve the postoperative outcome of cardiac surgical patients remains uncertain. An adequately powered randomized controlled trial appears desirable. Design Single blinded, international, multicenter randomized controlled trial with 1:1 allocation ratio. Setting Tertiary and University hospitals. Interventions Patients (n = 10,600) undergoing coronary artery bypass graft will be randomized to receive either volatile anesthetic as part of the anesthetic plan, or total intravenous anesthesia. Measurements and main results The primary end point of the study will be one-year mortality (any cause). Secondary endpoints will be 30-day mortality; 30-day death or non-fatal myocardial infarction (composite endpoint); cardiac mortality at 30 day and at one year; incidence of hospital re-admission during the one year follow-up period and duration of intensive care unit, and hospital stay. The sample size is based on the hypothesis that volatile anesthetics will reduce 1-year unadjusted mortality from 3% to 2%, using a two-sided alpha error of 0.05, and a power of 0.9. Conclusions The trial will determine whether the simple intervention of adding a volatile anesthetic, an intervention that can be implemented by all anesthesiologists, can improve one-year survival in patients undergoing coronary artery bypass graft surgery.

INTRODUCTION/PURPOSE: Increasing demand for training in focused cardiac ultrasound (FCU) is constrained by availability of supervisors to supervise training on patients. We designed and tested the feasibility of a cloud-based (internet) system that enables remote supervision and monitoring of the learning curve of image quality and interpretative accuracy for one novice learner. METHODS: After initial training in FCU (iHeartScan and FCU TTE Course, University of Melbourne), a novice submitted the images and interpretation of 30 practice FCU examinations on hospitalised patients to a supervisor via a cloud-based portal. Electronic feedback was provided by the supervisor prior to the novice performing each FCU examination, which included image quality score (for each view) and interpretation errors. The primary outcome of the study was the number of FCU scans required for two consecutive scans to score: (i) above the lower limit of acceptable total image quality score (64%), and (ii) below the upper limit of acceptable interpretive errors (15%). RESULTS: The number of FCU practice examinations required to meet adequate image quality and interpretation error standard was 10 and 13, respectively. Improvement in image acquisition continued, remaining within limits of acceptable image quality. Conversely, interpretive in-accuracy (error > 15%) continued. CONCLUSION: This electronic FCU mentoring system circumvents (but should not replace) the requirement for bed-side supervision, which may increase the capacity of supervision of physicians learning FCU. The system also allows real-time tracking of their progress and identifies weaknesses that may assist in guiding further training.

BACKGROUND: Studies have described different recovery profiles of sevoflurane and desflurane typically early after surgery. METHODS: We conducted a randomized superiority trial to determine whether Overall Recovery 3 days after knee arthroscopy would be superior with desflurane. Adult participants undergoing knee arthroscopic surgery with general anesthesia were randomized to either desflurane or sevoflurane general anesthesia. Intraoperative and postoperative drugs and analgesics were administered at the discretion of the anesthesiologist. Postoperative quality of recovery was assessed using the "Postoperative Quality of Recovery Scale". The primary outcome was Overall Recovery 3 days after surgery and secondary outcomes were individual recovery domains at 15 minutes, 40 minutes, 1 day, 3 days, 1 month, and 3 months. Patients and researchers were blinded. RESULTS: 300 patients were randomized to sevoflurane or desflurane (age 51.7±14.1 vs. 47.3±13.5 years; duration of anesthesia 24.9±11.1 vs. 23.3±8.3 minutes). The proportion achieving baseline or better scores in all domains increased over the follow-up period in both groups but was not different at day 3 (sevoflurane 43% vs. desflurane 37%, p = 0.314). Similarly, rates of recovery increased over time in the five subdomains, with no differences between groups for physiological, p = 0.222; nociceptive, p = 0.391; emotive, p = 0.30; Activities-of-daily-living, p = 0.593; and cognitive recovery, p = 0.877. CONCLUSION: No significant difference in the quality of recovery scale could be shown using sevoflurane or desflurane general anesthesia after knee arthroscopy in adult participants.

Ultrasound is increasingly being adopted into anaesthesia and intensive care practice. The range of ultrasound examination has also increased from transoesophageal echocardiography in cardiac surgery and ultrasound-guided nerve blocks and vascular access, to examination of the heart, lungs, abdomen and deep veins. Typically, the use of ultrasound is focused or basic, designed to be performed by the anaesthetist at the patient's bedside in real time to answer clinical questions and to direct therapy. Ultrasound is not performed in isolation, but used to complement clinical evaluation, and accordingly can be considered as 'ultrasound-assisted perioperative evaluation'. Whilst there is good evidence that ultrasound improves diagnostic accuracy and in turn alters management, there are few data examining whether ultrasound leads to improved clinical outcomes. This review will examine multiple uses of perioperative ultrasound with case studies to illustrate potential utility.Copyright © 2018 Australasian Society for Ultrasound in Medicine

Introduction: Focused transthoracic echocardiography (TTE) has emerged as a vital skill for the cardiothoracic anaesthetist to evaluate haemodynamic state and cardiac pathology in realtime. However, its use is restricted in patients after cardiac surgery due to reported poor image quality. The aim of this study was to determine the proportion of patients in whom haemodynamic state assessment is possible using a focused TTE protocol at repeated intervals after cardiac surgery. Method(s): Retrospective sub-study of a published prospective observational study of 91 adults undergoing coronary artery, valve and aortic surgery (1). Patients received TTE before, and at three time points after cardiac surgery. Images were assessed offline using a validated image quality score by two expert observers. Haemodynamic state was assessed using the iHeartScan protocol, which integrates left and right ventricular volumes, contractility, and left atrial filling pressure. Significant valvular pathology was discriminated using colour flow Doppler and two-dimensional assessment without requirement of spectral Doppler. The primary endpoint was the proportion of patients with at least one window in which the haemodynamic state was interpretable at each of the four time points. Result(s): In total, 51 patients were included in which haemodynamic state interpretability varied over time being highest before surgery (90%) and lowest on the first postoperative day (49%) (p<0.01). Variation in interpretability over time occurred in all three transthoracic windows ranging from 43% to 80% before surgery and from 2% to 35 on the first day after surgery (p<0.01). Similar variations over time were seen in terms of interpretability of function of aortic valve: 96% to 100% before surgery depending on the window and 59% to 82% on first postoperative day, mitral valve: 65% to 100% before surgery and 4% to 90% on first postoperative day, pulmonary valve: 80% before surgery and 41% on first postoperative

Purpose: Focused cardiac ultrasound (FCU) training in critical care is restricted by availability of instructors. Supervised training may be substituted by self-directed learning with an ultrasound simulator guided by automated electronic learning, enabling scalability. Material(s) and Method(s): We prospectively compared learning outcomes in novice critical care physicians after completion of a supervised one-and-a-half-day workshop model with a self-guided course utilizing a simulator over four weeks. Both groups had identical pre-workshop on-line learning (20h). Image quality scores were compared using FCU performed on humans without pathology. Interpretive knowledge was compared using 20MCQ tests. Result(s): Of 161 eligible, 145 participants consented. Total Image quality scores were higher in the Simulator group (95.2% vs. 66.0%, P <.001) and also higher for each view (all P <.001). Interpretive knowledge was not different before (78.6% vs. 79.0%) and after practical training (74.7% vs. 76.1%) and at 3 months (81.0% vs. 77.0%, all P >.1). Including purchase of the simulator and ultrasound equipment, the simulator course required lower direct costs (AUD$796 vs. $1724 per participant) and instructor time (0.5 vs.1.5 days) but similar participant time (2.8 vs. 3.0 days). Conclusion(s): Self-directed learning with ultrasound simulators may be a scalable alternative to conventional supervised teaching with human models.Copyright © 2018 Elsevier Inc.

Introduction: Lung ultrasound (LU) is superior to clinical examination and chest X-ray (CXR) in diagnosis of acute respiratory pathology in critical care but has not been reported before and after cardiothoracic surgery on the ward. The aim of this study was to determine the proportion of clinically significant respiratory pathology detectable with CXR, clinical examination, and lung ultrasound in patients on the ward before and after cardiothoracic surgery. Method(s): Prospective observational study in consenting patients who received a CXR on the ward before or after cardiac or thoracic surgery. Two clinicians performed standardised clinical assessment followed by LU. Incidence of atelectasis, consolidation, alveolar-interstitial syndrome, pleural effusion and pneumothorax were compared between clinical examination, CXR and LU (Reference method) using pre-defined diagnostic criteria in three lung zones by two blinded observers. Result(s): In 78 participants included, presence of any pathology was detected in 56% of the cohort by lung ultrasound; 24% preoperatively and 94% postoperatively. Intraobserver agreement of was better with LU (0.84-0.97) than clinical examination (0.28-0.70). Pathology was found with LU in 32 % of lung zones, and included atelectasis (11% of zones), effusion (9%), alveolar interstitial syndrome (5%), consolidation (4%) and pneumothorax (2.5%). Compared with LU, agreement in diagnosis of the 5 lung pathologies was poor (CXR 42%, clinical examination 34% and combined 56%), sensitivity was poor to modest (CXR 7-69%, clinical examination 7-76% and combined 14-94%) and specificity was good (CXR 84-98%, clinical examination 90%-99% and from combined 82%-97%), and correlation was modest (CXR 0.11-0.64 and clinical examination 0.08-0.7). Correlation between clinical examination and CXR was poor (0-0.58). Discussion(s): Clinically important respiratory pathology is detectable by lung ultrasound in a substantial number of noncritically ill, pre or p

Ultrasound is increasingly being adopted into anaesthesia and intensive care practice. The range of ultrasound examination has also increased from transoesophageal echocardiography in cardiac surgery and ultrasound-guided nerve blocks and vascular access, to examination of the heart, lungs, abdomen and deep veins. Typically, the use of ultrasound is focused or basic, designed to be performed by the anaesthetist at the patient's bedside in real time to answer clinical questions and to direct therapy. Ultrasound is not performed in isolation, but used to complement clinical evaluation, and accordingly can be considered as 'ultrasound-assisted perioperative evaluation'. Whilst there is good evidence that ultrasound improves diagnostic accuracy and in turn alters management, there are few data examining whether ultrasound leads to improved clinical outcomes. This review will examine multiple uses of perioperative ultrasound with case studies to illustrate potential utility.Copyright © 2018 Australasian Society for Ultrasound in Medicine

Purpose: Focused cardiac ultrasound (FCU) training in critical care is restricted by availability of instructors. Supervised training may be substituted by self-directed learning with an ultrasound simulator guided by automated electronic learning, enabling scalability. Material(s) and Method(s): We prospectively compared learning outcomes in novice critical care physicians after completion of a supervised one-and-a-half-day workshop model with a self-guided course utilizing a simulator over four weeks. Both groups had identical pre-workshop on-line learning (20h). Image quality scores were compared using FCU performed on humans without pathology. Interpretive knowledge was compared using 20MCQ tests. Result(s): Of 161 eligible, 145 participants consented. Total Image quality scores were higher in the Simulator group (95.2% vs. 66.0%, P <.001) and also higher for each view (all P <.001). Interpretive knowledge was not different before (78.6% vs. 79.0%) and after practical training (74.7% vs. 76.1%) and at 3 months (81.0% vs. 77.0%, all P >.1). Including purchase of the simulator and ultrasound equipment, the simulator course required lower direct costs (AUD$796 vs. $1724 per participant) and instructor time (0.5 vs.1.5 days) but similar participant time (2.8 vs. 3.0 days). Conclusion(s): Self-directed learning with ultrasound simulators may be a scalable alternative to conventional supervised teaching with human models.Copyright © 2018 Elsevier Inc.

Introduction: Focused transthoracic echocardiography (TTE) has emerged as a vital skill for the cardiothoracic anaesthetist to evaluate haemodynamic state and cardiac pathology in realtime. However, its use is restricted in patients after cardiac surgery due to reported poor image quality. The aim of this study was to determine the proportion of patients in whom haemodynamic state assessment is possible using a focused TTE protocol at repeated intervals after cardiac surgery. Method(s): Retrospective sub-study of a published prospective observational study of 91 adults undergoing coronary artery, valve and aortic surgery (1). Patients received TTE before, and at three time points after cardiac surgery. Images were assessed offline using a validated image quality score by two expert observers. Haemodynamic state was assessed using the iHeartScan protocol, which integrates left and right ventricular volumes, contractility, and left atrial filling pressure. Significant valvular pathology was discriminated using colour flow Doppler and two-dimensional assessment without requirement of spectral Doppler. The primary endpoint was the proportion of patients with at least one window in which the haemodynamic state was interpretable at each of the four time points. Result(s): In total, 51 patients were included in which haemodynamic state interpretability varied over time being highest before surgery (90%) and lowest on the first postoperative day (49%) (p<0.01). Variation in interpretability over time occurred in all three transthoracic windows ranging from 43% to 80% before surgery and from 2% to 35 on the first day after surgery (p<0.01). Similar variations over time were seen in terms of interpretability of function of aortic valve: 96% to 100% before surgery depending on the window and 59% to 82% on first postoperative day, mitral valve: 65% to 100% before surgery and 4% to 90% on first postoperative day, pulmonary valve: 80% before surgery and 41% on first postoperative

Introduction: Lung ultrasound (LU) is superior to clinical examination and chest X-ray (CXR) in diagnosis of acute respiratory pathology in critical care but has not been reported before and after cardiothoracic surgery on the ward. The aim of this study was to determine the proportion of clinically significant respiratory pathology detectable with CXR, clinical examination, and lung ultrasound in patients on the ward before and after cardiothoracic surgery. Method(s): Prospective observational study in consenting patients who received a CXR on the ward before or after cardiac or thoracic surgery. Two clinicians performed standardised clinical assessment followed by LU. Incidence of atelectasis, consolidation, alveolar-interstitial syndrome, pleural effusion and pneumothorax were compared between clinical examination, CXR and LU (Reference method) using pre-defined diagnostic criteria in three lung zones by two blinded observers. Result(s): In 78 participants included, presence of any pathology was detected in 56% of the cohort by lung ultrasound; 24% preoperatively and 94% postoperatively. Intraobserver agreement of was better with LU (0.84-0.97) than clinical examination (0.28-0.70). Pathology was found with LU in 32 % of lung zones, and included atelectasis (11% of zones), effusion (9%), alveolar interstitial syndrome (5%), consolidation (4%) and pneumothorax (2.5%). Compared with LU, agreement in diagnosis of the 5 lung pathologies was poor (CXR 42%, clinical examination 34% and combined 56%), sensitivity was poor to modest (CXR 7-69%, clinical examination 7-76% and combined 14-94%) and specificity was good (CXR 84-98%, clinical examination 90%-99% and from combined 82%-97%), and correlation was modest (CXR 0.11-0.64 and clinical examination 0.08-0.7). Correlation between clinical examination and CXR was poor (0-0.58). Discussion(s): Clinically important respiratory pathology is detectable by lung ultrasound in a substantial number of noncritically ill, pre or p

Hip fracture surgery is common, usually occurs in elderly patients who have multiple comorbidities, and is associated with high morbidity and mortality. Pre-operative focused cardiac ultrasound can alter diagnosis and management, but its impact on outcome remains uncertain. This pilot study assessed feasibility and group separation for a proposed large randomised clinical trial of the impact of pre-operative focused cardiac ultrasound on patient outcome after hip fracture surgery. Adult patients requiring hip fracture surgery in four teaching hospitals in Australia were randomly allocated to receive focused cardiac ultrasound before surgery or not. The primary composite outcome was any death, acute kidney injury, non-fatal myocardial infarction, cerebrovascular accident, pulmonary embolism or cardiopulmonary arrest within 30 days of surgery. Of the 175 patients screened, 100 were included as trial participants (screening:recruitment ratio 1.7:1), 49 in the ultrasound group and 51 as controls. There was one protocol failure among those recruited. The primary composite outcome occurred in seven of the ultrasound group patients and 12 of the control group patients (relative group separation 39%). Death, acute kidney injury and cerebrovascular accident were recorded, but no cases of myocardial infarction, pulmonary embolism or cardiopulmonary arrest ocurred. Focused cardiac ultrasound altered the management of 17 participants, suggesting an effect mechanism. This pilot study demonstrated that enrolment and the protocol are feasible, that the primary composite outcome is appropriate, and that there is a treatment effect favouring focused cardiac ultrasound – and therefore supports a large randomised clinical trial.

Ultrasound is increasingly being adopted into anaesthesia and intensive care practice. The range of ultrasound examination has also increased from transoesophageal echocardiography in cardiac surgery and ultrasound-guided nerve blocks and vascular access, to examination of the heart, lungs, abdomen and deep veins. Typically, the use of ultrasound is focused or basic, designed to be performed by the anaesthetist at the patient's bedside in real time to answer clinical questions and to direct therapy. Ultrasound is not performed in isolation, but used to complement clinical evaluation, and accordingly can be considered as 'ultrasound-assisted perioperative evaluation'. Whilst there is good evidence that ultrasound improves diagnostic accuracy and in turn alters management, there are few data examining whether ultrasound leads to improved clinical outcomes. This review will examine multiple uses of perioperative ultrasound with case studies to illustrate potential utility.

Hip fracture surgery is common, usually occurs in elderly patients who have multiple comorbidities, and is associated with high morbidity and mortality. Pre-operative focused cardiac ultrasound can alter diagnosis and management, but its impact on outcome remains uncertain. This pilot study assessed feasibility and group separation for a proposed large randomised clinical trial of the impact of pre-operative focused cardiac ultrasound on patient outcome after hip fracture surgery. Adult patients requiring hip fracture surgery in four teaching hospitals in Australia were randomly allocated to receive focused cardiac ultrasound before surgery or not. The primary composite outcome was any death, acute kidney injury, non-fatal myocardial infarction, cerebrovascular accident, pulmonary embolism or cardiopulmonary arrest within 30 days of surgery. Of the 175 patients screened, 100 were included as trial participants (screening:recruitment ratio 1.7:1), 49 in the ultrasound group and 51 as controls. There was one protocol failure among those recruited. The primary composite outcome occurred in seven of the ultrasound group patients and 12 of the control group patients (relative group separation 39%). Death, acute kidney injury and cerebrovascular accident were recorded, but no cases of myocardial infarction, pulmonary embolism or cardiopulmonary arrest ocurred. Focused cardiac ultrasound altered the management of 17 participants, suggesting an effect mechanism. This pilot study demonstrated that enrolment and the protocol are feasible, that the primary composite outcome is appropriate, and that there is a treatment effect favouring focused cardiac ultrasound – and therefore supports a large randomised clinical trial.

OBJECTIVES: Saphenous vein graft (SVG) remains the predominant conduit used in coronary surgery. The internal mammary artery has higher later term patency and confers superior survival. Current debate focuses on the increased use of arterial conduits rather than eradication of venous conduits. METHODS: Patient data extracted from the Australian and New Zealand Society of Cardiothoracic Surgeons database from 2001–2013 were linked to the national death registry held by the Australian Institute of Health and Welfare for all-cause mortality with censor date 7 October 2014. The dataset was divided according to use of SVG rather than the arterial conduit. Analyses of SVG ≥ 1 or SVG = 1 were compared to SVG = 0. Additionally, groups of 3, 4 or 5 grafts were subjected to multiple analyses testing the mortality hazard with increasing use of SVG. Propensity score matched analyses were conducted using 24 variables. RESULTS: Of 51 113 primary coronary surgery patients, unmatched survival at up to 12.5 years was significantly lower for SVG ≥ 1, n = 33 359, mortality hazard ratio (HR) 1.24 [95% confidence interval (CI) 1.18–1.30], P < 0.001; and for SVG = 1, mortality HR 1.19 (95% CI 1.12–1.26), P < 0.001. Similar results were present for the propensity score matched groups; SVG ≥ 1, n = 14 355 pairs, HR 1.22 (95% CI 1.15–1.30), P < 0.001; and for SVG = 1, n = 12 316 pairs, HR 1.22 (95% CI 1.14–1.30), P < 0.001. All matched analyses within restricted graft groups had increasing HR with increased number of SVG used. CONCLUSIONS: Any use of SVGs is independently associated with reduced survival after coronary artery bypass surgery.

BACKGROUND: The routine implementation of sternal precautions to prevent sternal complications that restrict the use of the upper limbs is currently worldwide practice following a median sternotomy. However, evidence is limited and drawn primarily from cadaver studies and orthopaedic research. Sternal precautions may delay recovery, prolong hospital discharge and be overly restrictive. Recent research has shown that upper limb exercise reduces post-operative sternal pain and results in minimal micromotion between the sternal edges as measured by ultrasound. The aims of this study are to evaluate the effects of modified sternal precautions on physical function, pain, recovery and health-related quality of life after cardiac surgery. METHODS/DESIGN: This study is a phase II, double-blind, randomised controlled trial with concealed allocation, blinding of patients and assessors, and intention-to-treat analysis. Patients (n = 72) will be recruited following cardiac surgery via a median sternotomy. Sample size calculations were based on the minimal important difference (two points) for the primary outcome: Short Physical Performance Battery. Thirty-six participants are required per group to counter dropout (20%). All participants will be randomised to receive either standard or modified sternal precautions. The intervention group will receive guidelines encouraging the safe use of the upper limbs. Secondary outcomes are upper limb function, pain, kinesiophobia and health-related quality of life. Descriptive statistics will be used to summarise data. The primary hypothesis will be examined by repeated-measures analysis of variance to evaluate the changes from baseline to 4 weeks post-operatively in the intervention arm compared with the usual-care arm. In all tests to be conducted, a p value <0.05 (two-tailed) will be considered statistically significant, and confidence intervals will be reported. DISCUSSION: The Sternal Management Accelerated Recovery Trial (S.M.A.R.T.)

Introduction. Transpulmonary thermodilution (TD) is the most used method for cardiac output (CO) monitoring during cardiac surgery. Although 2D transoesophageal (TOE) measurement of CO using spectral Doppler correlates with TD, 3D TOE more accurately measures left ventricular outflow tract (LVOT) and aortic valve (AV) area, which are used to calculate CO. The aim of this study is to compare the precision of CO measurement between 2D and 3D TOE against TD. Method. After ethics approval, 50 patients aged over 18 years scheduled for on-bypass cardiac surgery were recruited prospectively at two institutions. Exclusion criteria included more than mild valvular regurgitation, and atrial fibrillation. CO was measured simultaneously by TD and TOE before sternotomy and after cardiopulmonary bypass. CO was calculated using TOE by the product of either the LVOT or AV area, the velocity-time integral (VTI) of flow at the same site and heart rate. The LVOT area was assumed circular and calculated using the LVOT diameter for 2D but with planimetry using 3D TOE. The AV area was estimated with planimetry by both 2D and 3D TOE, and VTI with continuous wave Doppler. Both modal and outer edge traces of LVOT VTI were performed with the cursor 0.5 cm from the annulus. Measurements were averaged from 3 consecutive beats by 2 observers. Deming model II regression was used to assess fixed and proportional bias of agreement with TD. Bland-Altman technique was used to assess closeness of fit. Results. CO was measured at 94 time-points (50 before sternotomy, 44 after chest closure) in 50 patients. The 3D methods had better agreement than 2D with TD, with the best agreement with 3D planimetry of the AV (bias -0.04 Lmin-1, SD of difference between the mean 1.37 Lmin-1), followed by 3D LVOT area planimetry (0.14, 1.41), 2D AV area planimetry (0.28, 1.3) and 2D LVOT VTI outer edge trace (-0.59, 1.29). 3D LVOT area planimetry had the best correlation (slope 1.39, 95%CI 0.97-1.82), followed by 2D A

Purpose: Transpulmonary thermodilution (TD) is the gold standard for cardiac output (CO) monitoring during cardiac surgery but is feasible with TOE, but 2D TOE underestimates CO due to assumption of a circular LVOT, when 3D TOE demonstrates it is ovoid. The aim of this study is to determine if 3D TOE correlates better with TD than 2-D TOE. Methodology: After ethics approval, 50 adult patients without more than mild valvular regurgitation or A who were scheduled for bypass cardiac surgery were recruited prospectively at two institutions. CO was measured simultaneously by TD and TOE (2D/3D) before and after CPB. CO was calculated using the continuity method (product of VTI, area and heart rate) using the modal and outer-edge trace of the LVOT VTI. The aortic valve area was estimated with planimetry by both 2D and 3D TOE. Agreement analysis was performed using the Deming model II regression analysis and Bland-Altman technique (TD as the reference method). Results: Proportional but not fixed bias was present for the VTI modal method but not for any other method. Correlation for LVOT modal was poor (0.40) and CO was underestimated (mean bias = -1.59 L.min-1), but the limits of agreement were similar to other methods. Tracing the edge of the LVOT VTI rather than the modal line reduced the bias (-0.59 L.min-1), and improved correlation (0.92). 3D planimetry of the AV and continuous wave Doppler had the best agreement with TD. The mean bias approached zero for the 3D methods but with similar limits of agreement. Conclusion: For 2D measurements, tracing around the LVOT VTI rather than through the modal line improved precision. The other 2D and 3D measurements of CO showed absence of bias, and reasonable agreement with TD.

BACKGROUND: Ultrasound-assisted examination of the cardiovascular system with focused cardiac ultrasound by the treating physician is non-invasive and changes diagnosis and management of patient's with suspected cardiac disease. This has not been reported in a general practice setting. AIM: To determine whether focused cardiac ultrasound performed on patients aged over 50 years changes the diagnosis and management of cardiac disease by a general practitioner. DESIGN AND SETTING: A prospective observational study of 80 patients aged over 50years and who had not received echocardiography or chest CT within 12months presenting to a general practice. METHOD: Clinical assessment and management of significant cardiac disorders in patients presenting to general practitioners were recorded before and after focused cardiac ultrasound. Echocardiography was performed by a medical student with sufficient training, which was verified by an expert. Differences in diagnosis and management between conventional and ultrasound-assisted assessment were recorded. RESULTS AND CONCLUSION: Echocardiography and interpretation were acceptable in all patients. Significant cardiac disease was detected in 16 (20%) patients, including aortic stenosis in 9 (11%) and cardiac failure in 7 (9%), which were missed by clinical examination in 10 (62.5%) of these patients. Changes in management occurred in 12 patients (15% overall and 75% of those found to have significant cardiac disease) including referral for diagnostic echocardiography in 8 (10%), commencement of heart failure treatment in 3 (4%) and referral to a cardiologist in 1 patient (1%).Routine focused cardiac ultrasound is feasible and frequently alters the diagnosis and management of cardiac disease in patients aged over 50years presenting to a general practice.

Quality of recovery is a complex construct whose definition is influenced heavily by the opinions and biases of the individual patient, clinician, or institution. Asa result, recovery assessment tools differ in their fundamental definitions of recovery, breadth, and assessment time frame. Accurate assessment of recovery is essential as suboptimal recovery has both economic and prognostic implications. Quality of care is often substituted as a surrogate at the institutional level for quality of recovery, but it is ideologically distinct from patients' perceived quality of care, recovery, and satisfaction. Recovery tools also differ in their assessment of recovery as a continuous vs dichotomous variable and in their focus at the group vs individual level. Ideally, recovery measures should assess outcomes in a simple dichotomous fashion and maintain relevancy by assessing in multiple domains at various time points. Assessment of recovery in a dichotomous fashion also has both clinical and research applications. It allows identification of suboptimal recovery at both individual and group levels,respectively, and when performed in real time, it allows the opportunity for timely targeted intervention specific to individual patients as well as for resource rationalization.

Purpose: Transpulmonary thermodilution (TD) is the gold standard for cardiac output (CO) monitoring during cardiac surgery but is feasible with TOE, but 2D TOE underestimates CO due to assumption of a circular LVOT, when 3D TOE demonstrates it is ovoid. The aim of this study is to determine if 3D TOE correlates better with TD than 2-D TOE. Methodology: After ethics approval, 50 adult patients without more than mild valvular regurgitation or A who were scheduled for bypass cardiac surgery were recruited prospectively at two institutions. CO was measured simultaneously by TD and TOE (2D/3D) before and after CPB. CO was calculated using the continuity method (product of VTI, area and heart rate) using the modal and outer-edge trace of the LVOT VTI. The aortic valve area was estimated with planimetry by both 2D and 3D TOE. Agreement analysis was performed using the Deming model II regression analysis and Bland-Altman technique (TD as the reference method). Results: Proportional but not fixed bias was present for the VTI modal method but not for any other method. Correlation for LVOT modal was poor (0.40) and CO was underestimated (mean bias = -1.59 L.min-1), but the limits of agreement were similar to other methods. Tracing the edge of the LVOT VTI rather than the modal line reduced the bias (-0.59 L.min-1), and improved correlation (0.92). 3D planimetry of the AV and continuous wave Doppler had the best agreement with TD. The mean bias approached zero for the 3D methods but with similar limits of agreement. Conclusion: For 2D measurements, tracing around the LVOT VTI rather than through the modal line improved precision. The other 2D and 3D measurements of CO showed absence of bias, and reasonable agreement with TD.

Respiratory failure requiring mechanical ventilation has been reported in patients with bilateral diaphragmatic paralysis due to CIDP. We report a case of CIDP that progressed to respiratory failure with normal chest radiography despite unilateral diaphragmatic paralysis. This manifestation would have been missed if ultrasound was not employed.

To date, postoperative quality of recovery lacks a universally accepted definition and assessment technique. Current quality of recovery assessment tools vary in their development, breadth of assessment, validation, use of continuous vs dichotomous outcomes and focus on individual vs group recovery. They have progressed from identifying pure restitution of physiological parameters to multidimensional assessments of postoperative function and patient-focused outcomes. This review focuses on the progression of these tools towards an as yet unreached ideal that would provide multidimensional assessment of recovery over time at the individual and group level. A literature search identified 11 unique recovery assessment tools. The Postoperative Quality of Recovery Scale assesses recovery in multiple domains, including physiological, nociceptive, emotive, activities of daily living, cognition and patient satisfaction. It addresses recovery over time and compares individual patient data with base line, thus describing resumption of capacities and is an acceptable method for identification of individual patient recovery., Funding Agencies:Baxter HealthcareERAS Society Baxter

This prospective observational study investigated the effect of focused transthoracic echocardiography in 99 patients who had suspected cardiac disease or were ≥ 65 years old, and were scheduled for emergency non-cardiac surgery. The treating anaesthetist completed a diagnosis and management plan before and after transthoracic echocardiography, which was performed by an independent operator. Clinical examination rated cardiac disease present in 75%; the remainder were asymptomatic. The cardiac diagnosis was changed in 67% and the management plan in 44% of patients after echocardiography. Cardiac disease was identified by echocardiography in 64% of patients, which led to a step-up of treatment in 36% (4% delay for cardiology referral, 2% altered surgery, 4% intensive care and 26% intra-operative haemodynamic management changes). Absence of cardiac disease in 36% resulted in a step-down of treatment in 8% (no referral 3%, intensive care 1% or haemodynamic treatment 4%). Pre-operative focused transthoracic echocardiography in patients admitted for emergency surgery and with known cardiac disease or suspected to be at risk of cardiac disease frequently alters diagnosis and management.