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Introduction The Enhanced Recovery After Cardiac Surgery protocol is the most recent addition to cardiac treatment. In this paper, we aimed to test the safety and viability of this protocol in our hospital to improve our standard of care. Methods This study was conducted as an experimental study with a historical control at the Maritime Heart Center, Halifax, Nova Scotia, Canada. In order to quantify the success of this protocol, we measured the postoperative Length of Hospital Stay and three intensive care unit variables: time to extubation, time to ambulation, and opioid consumption. In the study, 100 patients were in the Enhanced Recovery After Cardiac Surgery group, and 103 patients were used as historic controls-selected by strenuous chart review and selection criteria. Results The primary outcome (Length of Hospital Stay) was reduced from a mean of 8.88 ± 3.50 days in the control group to a mean of 5.13 ± 1.34 days in the Enhanced Recovery After Cardiac Surgery group ( p Conclusion Enhanced Recovery After Cardiac Surgery protocols were seamlessly integrated into selected cardiac surgical patients, contingent on a high level of interprofessional communication and collaboration.

Aortic valve replacement (AVR) is one of the most common open-heart surgical procedures. The durability of the tissue valve in the aortic position is crucial in AVR and transcatheter AVR. We reviewed structural valve deterioration using echocardiographic follow-up in three types of surgical aortic tissue valves.A retrospective analysis was conducted where hemodynamic deterioration was evaluated and compared using transthoracic echocardiography, including pressure gradients and effective orifice area. Kaplan-Meier analyses were used to summarize the time to failure.The study included 133 Trifecta, 156 Epic, and 321 Magna Ease valves. Seventy-six percent (1941/2551) of patients had to be excluded due to insufficient echo data. Through univariate analysis, 34% (216/610) of valves met deterioration criteria after 24 months. Unadjusted survival curves showed a significant difference between valves (p ≤ .001), with a longer mean time to deterioration for the Magna Ease versus Trifecta and Epic of 68.9 versus 50.1 and 38.2 months, respectively. A Cox proportional hazard analysis found worse hazard ratios of 1.69 (p ≤ .04) and 2.4 (p ≤ .01) for Trifecta versus Magna and Epic versus Trifecta, respectively.All three valve types demonstrated structural valve deterioration on echocardiographic follow-up with significant differences in rate. The Magna Ease appeared to have the highest durability, and the Epic the lowest. Further investigation is warranted to confirm the results in a larger multicenter study.

Introduction: Marked variation among surgeons and relevant health care providers (HCPs) in aortic valve replacement (AVR) costs was demonstrated. Despite presentation of these data to HCPs, cost variation persists. We sought input from cardiac HCPsregarding intraoperative cost awareness, decision making and potential motivators towards greater cost consideration. Objectives: Three fold purpose: I) Determine the primary intraoperative cost drivers of performing an isolated AVR in a single-center Canadian hospital, II) Evaluate the impact of communicating cost and driver variability on decision making, and III) Identify the barriers and facilitators of incorporating cost considerations in isolated AVRs among HCPs. Methods: From May 2017-May 2019, data was collected on AVR cost drivers (n=216). There were three phases of data feedback to HCPs. Separate focus groups were held (Phase III) for cardiac HCPs including surgeons, anesthesiologists, perfusionists , residents, and OR nurses (n=27). Semi-structured interviews were used to elicit provider perspectives. Transcribed audio data was analyzed through the use of thematic analysis to develop a core set of common and comprehensive themes. Results: Data collection demonstrated marked inter-surgeon variation around the surgical costs of procedures. After feedback to HCPs, variation persisted and the median cost for AVRs increased. Five themes were identified from HCP groups: cost awareness, intraoperative decision making, influence surrounding intraoperative cost decision making, provider-based motivation for implementing intraoperative cost decision making, and cost drivers for an AVR. Conclusions: No difference in cost or variation before and after data feedback to HCPs was insufficient to impact surgeon’s behaviour in case costing, which motivated the qualitative work in the form of focus groups. HCPs demonstrated low cost awareness regarding cost drivers of AVRs. They expressed interest in engaging in cost decision making that was informed by cost containment. Measures such as listing the price of cost drivers in the OR and providing cost feedback could potentially encourage engagement in cost decision making for AVRs.

Objectives To compare transabdominal sonography (TAS) to transvaginal sonography (TVS) in medical abortion eligibility assessment, specifically to measure how often clinicians chose to order additional testing for eligibility assessment following TAS and TVS, and to look for differences by patient and clinician characteristics. Also, to compare patient acceptability between the two modalities. Study design This pragmatic multisite randomized noninferiority trial compared TAS to TVS at 10 New York City and New Jersey health centers that provide medical abortion. Women seeking medical abortion were randomized 1:1 to receive TAS or TVS. Following the study ultrasound examination, clinicians determined whether participants were eligible for medical abortion based on these results or warranted further testing. All participants completed an acceptability questionnaire. We compared additional testing and acceptability between TAS and TVS. Results Of those randomized to TAS, 63/317 (19.9%) received additional testing compared to 15/312 (4.8%) randomized to TVS. After TAS, most additional testing consisted of a same-day TVS. Other tests included β-hCG testing, scheduled repeat sonography or return visit. After TAS, 13.4% seen by physicians and 27.6% seen by advanced practice nurses (APNs) received additional testing (p 35 kg/m2 to make comparisons. Participants found TAS more acceptable than TVS, and two thirds preferred TAS for future care. Conclusions TAS provided sufficient information for clinicians to assess medical abortion eligibility without additional tests for most patients. However, the frequency of additional testing was exceedingly close to our predefined noninferiority boundary. Why APNs ordered substantially more additional testing than physicians is unclear. TAS was more acceptable to patients than TVS. Implications TVS use requires high-level disinfection, which is resource-intensive and thus can be a barrier to care. Instead, TAS can be first-line for most women, reducing resources needed to provide medical abortion. Further research could help to establish gestational age and BMI thresholds beyond which TVS would be a more informative first test. We also need to evaluate whether additional training in using TAS would decrease additional testing.

BACKGROUND: Patients with peripheral artery disease have an increased risk of cardiovascular morbidity and mortality. Antiplatelet agents are widely used to reduce these complications.METHODS: This was a multicentre, double-blind, randomised placebo-controlled trial for which patients were recruited at 602 hospitals, clinics, or community practices from 33 countries across six continents. Eligible patients had a history of peripheral artery disease of the lower extremities (previous peripheral bypass surgery or angioplasty, limb or foot amputation, intermittent claudication with objective evidence of peripheral artery disease), of the carotid arteries (previous carotid artery revascularisation or asymptomatic carotid artery stenosis of at least 50%), or coronary artery disease with an ankle-brachial index of less than 0·90. After a 30-day run-in period, patients were randomly assigned (1:1:1) to receive oral rivaroxaban (2·5 mg twice a day) plus aspirin (100 mg once a day), rivaroxaban twice a day (5 mg with aspirin placebo once a day), or to aspirin once a day (100 mg and rivaroxaban placebo twice a day). Randomisation was computer generated. Each treatment group was double dummy, and the patient, investigators, and central study staff were masked to treatment allocation. The primary outcome was cardiovascular death, myocardial infarction or stroke; the primary peripheral artery disease outcome was major adverse limb events including major amputation. This trial is registered with ClinicalTrials.gov, number NCT01776424, and is closed to new participants.FINDINGS: Between March 12, 2013, and May 10, 2016, we enrolled 7470 patients with peripheral artery disease from 558 centres. The combination of rivaroxaban plus aspirin compared with aspirin alone reduced the composite endpoint of cardiovascular death, myocardial infarction, or stroke (126 [5%] of 2492 vs 174 [7%] of 2504; hazard ratio [HR] 0·72, 95% CI 0·57-0·90, p=0·0047), and major adverse limb events including major amputation (32 [1%] vs 60 [2%]; HR 0·54 95% CI 0·35-0·82, p=0·0037). Rivaroxaban 5 mg twice a day compared with aspirin alone did not significantly reduce the composite endpoint (149 [6%] of 2474 vs 174 [7%] of 2504; HR 0·86, 95% CI 0·69-1·08, p=0·19), but reduced major adverse limb events including major amputation (40 [2%] vs 60 [2%]; HR 0·67, 95% CI 0·45-1·00, p=0·05). The median duration of treatment was 21 months. The use of the rivaroxaban plus aspirin combination increased major bleeding compared with the aspirin alone group (77 [3%] of 2492 vs 48 [2%] of 2504; HR 1·61, 95% CI 1·12-2·31, p=0·0089), which was mainly gastrointestinal. Similarly, major bleeding occurred in 79 (3%) of 2474 patients with rivaroxaban 5 mg, and in 48 (2%) of 2504 in the aspirin alone group (HR 1·68, 95% CI 1·17-2·40; p=0·0043).INTERPRETATION: Low-dose rivaroxaban taken twice a day plus aspirin once a day reduced major adverse cardiovascular and limb events when compared with aspirin alone. Although major bleeding was increased, fatal or critical organ bleeding was not. This combination therapy represents an important advance in the management of patients with peripheral artery disease. Rivaroxaban alone did not significantly reduce major adverse cardiovascular events compared with asprin alone, but reduced major adverse limb events and increased major bleeding.FUNDING: Bayer AG.

The clinical performance of the Cobas CT/NG assay on the Cobas 6800/8800 systems (Cobas) for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae was established in a multisite, prospective collection study using male and female urogenital specimens; supportive data from archived specimens were also included. The results obtained with the Cobas assay were compared with the patient infected status derived from a combination of U.S., The clinical performance of the Cobas CT/NG assay on the Cobas 6800/8800 systems (Cobas) for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae was established in a multisite, prospective collection study using male and female urogenital specimens; supportive data from archived specimens were also included. The results obtained with the Cobas assay were compared with the patient infected status derived from a combination of U.S. Food and Drug Administration-approved nucleic acid amplification tests to determine the sensitivity and specificity of detection from each sample type. The sensitivity of Cobas for the detection of C. trachomatis in female specimens was 95.6% (95% confidence interval [CI], 92.4% to 97.4%) for urine; 98.6% (95% CI, 95.2% to 99.6%) and 99.2% (95% CI, 95.4% to 99.9%) for clinician- and self-collected vaginal swab specimens, respectively; 93.3% (95% CI, 89.6% to 95.7%) for endocervical swabs; and 92.5% (95% CI, 88.7% to 95.1%) for cervical swab samples in PreservCyt. The specificity for the detection of C. trachomatis was ≥98.8% for all female sample types. Sensitivity and specificity estimates of Cobas for the detection of C. trachomatis in male urine samples were 100% (96.8% to 100.0%) and 99.7% (95% CI, 99.2% to 99.9%), respectively. The sensitivity of Cobas for the detection of N. gonorrhoeae in female specimens was 94.8% (95% CI, 89.6% to 97.4%) for urine; 100.0% (95% CI, 87.9% to 100.0%) and 100.0% (95% CI, 87.9% to 100.0%) for clinician- and self-collected vaginal swab specimens, respectively; 97.0% (95% CI, 91.5% to 99.0%) for endocervical swabs; and 96.6% (95% CI, 90.6% to 98.8%) for cervical samples in PreservCyt; the specificity for all female sample types was >99.0%. The sensitivity and specificity of Cobas for detecting N. gonorrhoeae in male urine were 100.0% (95% CI, 95.8% to 100.0%) and 99.5% (95% CI, 98.8% to 99.8%), respectively. Fully automated assays help fill the clinical need for a sensitive, high-throughput screening tool to aid public health efforts to control C. trachomatis and N. gonorrhoeae infections.

BACKGROUND: Coronary artery disease is a major cause of morbidity and mortality worldwide, and is a consequence of acute thrombotic events involving activation of platelets and coagulation proteins. Factor Xa inhibitors and aspirin each reduce thrombotic events but have not yet been tested in combination or against each other in patients with stable coronary artery disease.METHODS: In this multicentre, double-blind, randomised, placebo-controlled, outpatient trial, patients with stable coronary artery disease or peripheral artery disease were recruited at 602 hospitals, clinics, or community centres in 33 countries. This paper reports on patients with coronary artery disease. Eligible patients with coronary artery disease had to have had a myocardial infarction in the past 20 years, multi-vessel coronary artery disease, history of stable or unstable angina, previous multi-vessel percutaneous coronary intervention, or previous multi-vessel coronary artery bypass graft surgery. After a 30-day run in period, patients were randomly assigned (1:1:1) to receive rivaroxaban (2·5 mg orally twice a day) plus aspirin (100 mg once a day), rivaroxaban alone (5 mg orally twice a day), or aspirin alone (100 mg orally once a day). Randomisation was computer generated. Each treatment group was double dummy, and the patients, investigators, and central study staff were masked to treatment allocation. The primary outcome of the COMPASS trial was the occurrence of myocardial infarction, stroke, or cardiovascular death. This trial is registered with ClinicalTrials.gov, number NCT01776424, and is closed to new participants.FINDINGS: Between March 12, 2013, and May 10, 2016, 27 395 patients were enrolled to the COMPASS trial, of whom 24 824 patients had stable coronary artery disease from 558 centres. The combination of rivaroxaban plus aspirin reduced the primary outcome more than aspirin alone (347 [4%] of 8313 vs 460 [6%] of 8261; hazard ratio [HR] 0·74, 95% CI 0·65-0·86, pINTERPRETATION: In patients with stable coronary artery disease, addition of rivaroxaban to aspirin lowered major vascular events, but increased major bleeding. There was no significant increase in intracranial bleeding or other critical organ bleeding. There was also a significant net benefit in favour of rivaroxaban plus aspirin and deaths were reduced by 23%. Thus, addition of rivaroxaban to aspirin has the potential to substantially reduce morbidity and mortality from coronary artery disease worldwide.FUNDING: Bayer AG.

A method for the in situ creation of field emission structures possessing highly desirable physical characteristics is described. Field emitters are produced by rapid solidification of electrostatically formed high-temperature Taylor cones formed on the ends of laser melted refractory-metal wires. The present state of the technology, progress to employ these field emitters in an ultrafast pulsed electron gun, and potential future advances are summarized.

A method for manufacturing metal monocapillary optics is described. The fabrication process begins by withdrawing an initially uniform wire from an etchant bath at a variable rate using a computer-controlled translation stage. This generates a precise taper profile on the wire that corresponds to the bore of a capillary that will be produced in subsequent steps. Paraboloidal, ellipsoidal or other capillary figures can be programmed into the motion controller. Two different methods are discussed for generating the completed optic from the etched wire. In both of these techniques, the wire functions as an expendable mandrel. In the first method, the wire is first coated with a radiation-reflecting material and then bonded to a rigid substrate. The wire is then dissolved using a chemical process to produce the hollow capillary optic. In the second method, a purely mechanical process imprints the wire figure into a softer material to create the capillary optic. Both manufacturing processes permit the production of capillaries that are accurately figured, extremely straight and have very low surface roughness. Wide latitude is possible in the selection of reflective materials that coat the internal surface of the optics. Experimental measurements using the optics with synchrotron radiation have demonstrated 5-10 μm diameter beams having flux-density gains near 100. Potential improvements to the capillaries for achieving higher gains and smaller sizes are discussed. In addition to synchrotron radiation experiments, applications with small laboratory instruments are considered. The ultimate limitations of the optics and their comparison with glass capillaries are discussed.

A novel method for creating conical field-emission structures possessing unusual and desirable physical characteristics is described. This process is accomplished by solidification of electrostatically formed high-temperature Taylor cones created on the ends of laser melted refractory-metal wires. Extremely rapid freezing ensures that the resultant solid structures preserve the shape and surface smoothness of the flawless liquid Taylor-cones to a very high degree. The method also enables in situ and rapid restoration of the frozen cones to their initial pristine state after undergoing physical degradation during use. This permits maximum current to be delivered without excessive concern for any associated reduction in field-emitter lifetime resulting from operation near or even above the damage threshold. In addition to the production of field emitters using polycrystalline wires as a substrate, the feasibility of producing monocrystalline frozen Taylor-cones having reproducible crystal orientation by gro...

Sulfur has a particularly rich biochemistry and fills a number of important roles in biology. In situ information on sulfur biochemistry is generally difficult to obtain because of a lack of biophysical techniques that have sufficient sensitivity to molecular form. We have recently reported that sulfur K-edge X-ray absorption spectroscopy can be used as a direct probe of the sulfur biochemistry of living mammalian cells [Gnida, M., et al. (2007) Biochemistry 46, 14735-14741]. Here we report an extension of this work and develop sulfur K-edge X-ray fluorescence spectroscopic imaging as an in vivo probe of sulfur metabolism in living cells. For this work, we have chosen onion (Allium cepa) as a tractable model system with well-developed sulfur biochemistry and present evidence of the localization of a number of different chemical forms. X-ray absorption spectroscopy of onion sections showed increased levels of lachrymatory factor (LF) and thiosulfinate and decreased levels of sulfoxide (LF precursor) following cell breakage. In intact cells, X-ray fluorescence spectroscopic imaging showed elevated levels of sulfoxides in the cytosol and elevated levels of reduced sulfur in the central transport vessels and bundle sheath cells.

Objective: To develop clinical practice guidelines for the support of the patient and family in the adult, pediatric, or neonatal patient-centered ICU. Participants: A multidisciplinary task force of experts in critical care practice was convened from the membership of the American College of Critical Care Medicine (ACCM) and the Society of Critical Care Medicine (SCCM) to include representation from adult, pediatric, and neonatal intensive care units. Evidence: The task force members reviewed the published literature. The Cochrane library, Cinahl, and MedLine were queried for articles published between 1980 and 2003. Studies were scored according to Cochrane methodology. Where evidence did not exist or was of a low level, consensus was derived from expert opinion. Consensus Process: The topic was divided into subheadings: decision making, family coping, staff stress related to family interactions, cultural support, spiritual/religious support, family visitation, family presence on rounds, family presence at resuscitation, family environment of care, and palliative care. Each section was led by one task force member. Each section draft was reviewed by the group and debated until consensus was achieved. The draft document was reviewed by a committee of the Board of Regents of the ACCM. After steering committee approval, the draft was approved by the SCCM Council and was again subjected to peer review by this journal. Conclusions: More than 300 related studies were reviewed. However, the level of evidence in most cases is at Cochrane level 4 or 5, indicating the need for further research. Forty-three recommendations are presented that include, but are not limited to, endorsement of a shared decision-making model, early and repeated care conferencing to reduce family stress and improve consistency in communication, honoring culturally appropriate requests for truth-telling and informed refusal, spiritual support, staff education and debriefing to minimize the impact of family interactions on staff health, family presence at both rounds and resuscitation, open flexible visitation, way-finding and familyfriendly signage, and family support before, during, and after a death. (Crit Care Med 2007; 35:605‐622)

The fern Pteris vittata accumulates unusually high levels of arsenic. Using X-ray absorption spectroscopy (XAS) and XAS imaging, we reveal the distribution of arsenic species in vivo. Arsenate is transported through the vascular tissue from the roots to the fronds (leaves), where it is reduced to arsenite and stored at high concentrations. Arsenic-thiolate species surrounding veins may be intermediates in this reduction. In gametophytes, arsenite is compartmentalized within the cell vacuole. Arsenic is excluded from cell walls, rhizoids, and reproductive areas. This study provides important insights into arsenic hyperaccumulation, which may prove useful for phytoremediating arsenic-contaminated sites, and demonstrates the strengths of XAS imaging for distinguishing highly localized species.

Multiple studies have shown that women have worse in-hospital outcomes than men after coronary artery bypass grafting (CABG). The impact of sex on long-term results following CABG, however, is not as well established.To compare long-term results in men and women undergoing CABG.A total of 3404 patients underwent isolated CABG between 1995 and 1999 with follow-up until 2000. Univariate comparisons between men and women were carried out based on pre- and intraoperative variables and short- and long-term adverse outcomes. Long-term adverse outcomes were defined as all-cause mortality or rehospitalization for any cardiac cause, and were risk-adjusted using multivariate modelling techniques.Compared with men, women undergoing CABG were, on average, older (67.8 years versus 64.2 years), more likely to have diabetes (P0.0001) and hypertension (P0.0001), and more likely to present for surgery with urgent/emergent status (P0.0001). Intra-operatively, women had fewer bypasses (3.0 versus 3.3; P0.0001) and were less likely to receive a left internal mammary artery graft (P=0.0001). While rates of in-hospital mortality were comparable between women and men (2.9% versus 2.2%; P=0.22), women were more likely to experience a long-term adverse event (30.2% versus 23.5%; P0.0001). After adjusting for clinical differences between men and women, sex emerged as an independent predictor of long-term adverse outcomes following CABG (hazard ratio = 1.18, P=0.03).Women presented for CABG with more comorbid illness, advanced symptoms and greater urgency than did men. After adjusting for differences in clinical presentation, sex emerged as an independent predictor of long-term adverse outcomes following CABG.

A novel method for fabricating metal monocapillary optics is described. The process begins by withdrawing an initially uniform wire from an etchant bath at a variable rate using a computer‐controlled motion stage. A precisely tapered wire results, which corresponds to the bore of a capillary optic to be produced in subsequent steps. Paraboloidal, ellipsoidal, or other wire shapes can be generated. After being placed between two highly polished plates composed of a soft metal, the wire figure is symmetrically imprinted into the surfaces of both plates by the application of pressure using a hydraulic press. The completed capillary optic is produced by removing the wire; cutting and polishing the ends of the plates to define the entrance and exit apertures; and reassembling the two halves. The manufacturing process permits the production of capillaries that are accurately figured, very straight, and have low surface‐roughness. Wide latitude in the selection of materials comprising the internal reflecting sur...

Imaging of biological specimens using a new type of soft x‐ray microscope is described. The instrument is significantly simpler in design than existing x‐ray microscopes. The technique used is a variation of the photoelectron‐conversion contact method. The instrument is very similar to the field emission microscope in geometry but uses special cone‐like hollow emitters instead of solid emitters. Specimens to be examined are placed inside the hollow emitter tips. Soft x rays are beamed down the axis of the hollow cone from the open end, through the specimen, and onto the hemispherical emitter tip membrane. An x‐ray contact image is thereby produced on the emitter tip, corresponding to the x‐ray absorption of the specimen. Photoelectrons are liberated into the vacuum, outside the emitter tip, in a pattern corresponding to the contact image of the specimen. A high voltage placed on the emitter accelerates the photoelectrons radially to a detector. The result is a magnified, high‐resolution, real‐time image. Experiments produced images of various dried fungi, bacterial, and mammalian cells with a resolution down to ≊1000 A.

The use of extremely small diameter x-ray beams at synchrotron radiation facilities has become an important experimental technique for investigators in many other scientific disciplines. While there have been several different optical elements developed for producing such microbeams, this SBIR project was concerned with one particular device: the tapered-monocapillary optic.

A new approach for producing tapered-moncapillary optics has been demonstrated. The fabrication process permits the production of metal optics which are accurately shaped, extremely straight, and have very low surface-roughness. Wide latitude in the selection of materials comprising the optics is possible. Preliminary experiments using gold paraboloidal-capillaries have demonstrated flux-density gains approaching 100 in 10-micron focused beams. The fabrication process, testing procedures, and experimental results are described. Potential improvements to the optics for achieving higher gains and smaller spot-sizes are discussed.

Tapered metal monocapillary optics provide a potential alternative to conventional methods of producing small X-ray beams. This paper presents the initial results of chemically specific imaging using such devices. Cellular resolution of organic selenium is obtained in a longitudinal section of mature Astragalus bisulcatus, a selenium hyperaccumulating plant. This work demonstrates the utility of metal monocapillary optics for imaging dilute levels of target elements in biological tissues.