Heparin coating of extracorporeal circuits inhibits contact activation during cardiac operations

OBJECTIVE: The choice of a valve substitute remains a challenge in young patients, with numerous reports of early degeneration and calcification of biological valves in this age group. Therefore an assessment of the long-term results after mechanical aortic valve replacement in children was initiated. METHODS: A retrospective study was conducted in 54 consecutive patients aged 1.1 to 17 years (mean 12.8 +/- 4 years) operated on between 1975 and 1993. Aetiology was congenital in 34 patients, rheumatic in 13, infectious in 5, and dystrophic in 2. Concomitant surgery included mitral valve replacement (10), aortic annulus enlargement (9), correction of truncus arteriosus (7), Bentall operation (2), coarctation repair (2), tricuspid valvuloplasty (2), correction of double outlet right ventricle (1), and replacement of a right ventricle to pulmonary artery conduit (1). A Bjork-Shiley valve was implanted in 14 patients, and a St Jude Medical valve in 40. All patients were given Warfarin with a monthly INR control. Follow-up was completed through questionnaires mailed to referring physicians and direct clinical examination. RESULTS: Overall early mortality was 13% (7 cases), and 6% (2 cases) in the 32 patients operated on after 1984. Follow-up was complete in 45 survivors (2 lost to follow-up), with a total follow-up of 261 patient-years. There were 6 late deaths, 4 being cardiac and due to persistent LV dysfunction, and 2 valve-related, due respectively to major gastro-intestinal bleeding and massive thromboembolism. Linearized rates of valve thrombosis and anticoagulant-related hemorrhage were both 0.3% per patient-year. Actuarial survival rate was respectively 84.5% at 5 years and 70.2% at 10 years. Reoperation was necessary in 3 patients for recurrent LV outflow tract obstruction. One patient with severe LV dysfunction is awaiting a heart transplant. CONCLUSION: We conclude that the longterm outcome after mechanical aortic valve replacement in children and adolescents is satisfactory and comparable to currently available reports on biological substitutes. The mandatory anticoagulant therapy is well tolerated in this age group.     

Inflammatory response to cardiopulmonary bypass using two different types of heparin-coated extracorporeal circuits

Previous reports have highlighted the disparity in biocompatibility of two differently engineered heparin coatings during the cardiopulmonary bypass (CPB) procedure. The aim of this prospective study was to evaluate the impact of the difference in haemocompatibility provided by either the Duraflo II equipment or the Carmeda equipment in the terminal inflammatory response observed after coronary artery surgery. Thirty patients were randomly allocated to two groups to be operated on using either Duraflo II equipment (group I) or Carmeda equipment (group 2) for extracorporeal circulation (ECC). Initial inflammatory response was assessed by terminal complement complex activation (SC5b-9). The late inflammatory response observed in the postoperative period was assessed by measuring cytokine production (tumour factor necrosis (TNF alpha), interleukin IL-6, interleukin IL-8) and circulating concentrations of adhesion molecules (ELAM-1, ICAM-1). The release of SC5b-9 after CPB and after protamine administration was lower in group 2 than in group 1 (p = 0.0002 and p = 0.006, respectively). A significant production of cytokines was detected in both groups with peak values observed within the time range of 4-6 h after the start of CPB.     

Reliability of velocity pulsatility in small vessels on 3Tesla MRI in the basal ganglia: a test–retest study

Objective

Recent work showed the feasibility of measuring velocity pulsatility in the perforating arteries at the level of the BG using 3T MRI. However, test–retest measurements have not been performed, yet. This study assessed the test–retest reliability of 3T MRI blood flow velocity measurements in perforating arteries in the BG.

Materials and methods

Two-dimensional phase-contrast cardiac gated (2D-PC) images were acquired for 35 healthy controls and repeated with and without repositioning. 2D-PC images were processed and analyzed, to assess the number of detected perforating arteries (N_detected), mean blood flow velocity (V_mean), and velocity pulsatility index (vPI). Paired t-tests and Bland–Altman plots were used to compare variance in outcome parameters with and without repositioning, and limits of agreement (LoA) were calculated.

Results

The LoA was smallest for V_mean (35%) and highest for vPI (79%). Test–retest reliability was similar with and without repositioning of the subject.

Discussion

We found similar LoA with and without repositioning indicating that the measurement uncertainty is dominated by scanner and physiological noise, rather than by planning. This enables to study hemodynamic parameters in perforating arteries at clinically available scanners, provided sufficiently large sample sizes are used to mitigate the contribution of scanner- and physiological noise.

     

Financial impact of a dioxin incident in the Dutch dairy chain

The aim of this study was to quantify the financial consequences of a milk-dioxin crisis on the stages of the dairy chain involved. The milk dioxin contamination impact model was designed for this purpose and also was used to estimate the net costs of control measures limiting the impact. Results obtained based on the assumption of the worst-case scenario in which the entire daily production of each business unit from feed supplier to milk processor is contaminated suggested that the financial impact of one dioxin incident would be ?41.2 million. Another assumption was that the dioxin contamination started at one feed processing plant and was detected 2 weeks after initial contamination (the high-risk period), which would result in the involvement of 714 dairy farms, 26 milk processors, and 2,664 retailers. The stages of the chain that contributed most to the total net costs were the milk processor (76.9%) and the dairy farm (20.5%). If the high-risk period were shorter, i.e., 3 days, the estimated total financial impact decreases to ?0.9 million. Thus, early detection of the contamination is crucial for decreasing the number of food businesses involved and lowering the total financial impact. The most influential inputs of the model were the sale price of milk at the processing stage, the daily amount of milk processed per processing plant, the farm-blocking period, and the daily amount of milk produced per farm. However, the effect of these inputs on the total financial impact was less than 10.0%. These results can be used to establish priorities in the application of control measures to limit the financial and public health impacts of a possible food safety incident.     

Short communication: Effectiveness of tools provided by a dairy company on udder health in Dutch dairy farms

A Dutch dairy company initiated a quality system to support dairy farmers to improve sustainability on their farm. Improvement of udder health is defined by the dairy company as one of the sustainability items. A part of that quality system is to offer farmers 3 tools to improve the udder health status of the herd. The first tool is an Udder Health Workshop at which farmers make a farm-specific action plan to improve the udder health situation in their herd. The second tool is the Udder Health Navigator, which is an internet-based program to gain insight in the actual udder health situation at the farm. The third tool is the Udder Health Checklist, which is available on the internet and it identifies farm-specific risks for udder health problems. The aim of this study was to evaluate the effectiveness of these tools in improving udder health. The bulk milk somatic cell count (BMSCC) was used as the measure of herd udder health performance. In total, 605 farms attended the Udder Health Workshop, 988 farms completed the Udder Health Navigator, and 1,855 farms completed the Udder Health Checklist in 2012. Information on BMSCC records (2 records per month) was available for 12,782 Dutch dairy farms during the years 2011 and 2012. For every farm, the average BMSCC of all months during the years 2012 and 2011 were calculated. This resulted in 306,768 average monthly observations of the BMSCC. Subsequently, all months after the completion of one of the tools were assigned a 1, and all other months were assigned a 0. A statistical analysis was carried out to compare the average monthly BMSCC of the farms that completed one or more tools with farms that did not complete one of the tools. Both completing the Udder Health Navigator and the Udder Health Checklist had a significant association with a lower average monthly BMSCC. The effect of the Udder Health Navigator and Udder Health Checklist on the BMSCC were greater in herds with a BMSCC in 2011 of 200,000 to 250,000 cells/mL and even greater for herds with a BMSCC above 250,000 cells/mL compared with herds with a BMSCC in 2011 of 150,000 to 200,000 cells/mL or less than 150,000 cells/mL. It is difficult to draw conclusions on the effect of the Udder Health Workshop due to overlap in participation between the tools. The results suggest that completing the web tools is associated with a reduction in the BMSCC of the herd.     

Factors associated with high antimicrobial use in young calves on Dutch dairy farms: A case-control study

Since 2012, the Dutch Veterinary Medicine Authority reports antimicrobial usage (AMU) in young calves (<56 d) on dairy farms on an annual basis. The AMU distribution in this age group is skewed, with a low AMU in young calves on the majority of dairy farms and a high AMU in a relatively small number of farms. This results in a notable difference between the mean and median AMU. To further reduce the mean AMU, the AMU on the high-AMU farms must be decreased. The objective of this study was to evaluate the association between both young stock management and an indication of the farmers' mindset and AMU in young calves on Dutch dairy farms with a high and low AMU in young calves. This knowledge may be helpful in decreasing AMU in young calves on high-AMU farms. We performed a case-control study in which 200 dairy farms (100 with high AMU and 100 with low AMU in young calves) participated. Case farms were defined as farms with an animal daily-defined dose at the farm level in young calves >28 in 2012 and 2013, based on the 90th percentile of the use of antimicrobials in young calves in 2012. Control farms had an animal daily-defined dose at the farm level in young calves of <0.5 in 2012 and 2013, which was determined to be low use. A questionnaire was conducted about general farm and young stock management, hygiene, housing, vaccination, and calf health. An indication of the farmers' mindset with regard to AMU and treatment of sick calves was determined by including statements (agree/disagree) in the questionnaire. In addition, routinely collected data on herd size, growth in herd size, replacement, and calf mortality were available for analysis. Dairy farmers that immediately started antimicrobial treatment in sick calves had higher odds of being in the high-AMU group than farmers who started treatment of sick calves with supportive nonantimicrobial therapy. Other variables associated with a high AMU in young calves included housing calves on partially slatted floors, a high prevalence of respiratory disease, an unfavorable Salmonella status, and not agreeing with the statement “Young stock need specific management.” Both dairy farm management and opinions of dairy producers regarding AMU, indicative of mindset, are important when distinguishing farms with high and low AMU in young calves. Although the rationale behind mindset warrants more research, likely a change in both aspects seems to be required to reduce the AMU in young calves on dairy farms.     

A baboon model for hematologic studies of cardiopulmonary bypass

Objective investigation of new inhibitors of blood protein or cellular systems that are activated during cardiopulmonary bypass (CPB) is impeded by the absence of a satisfactory animal model. Because most baboon hematologic proteins immunologically cross-react with those used for human assays, we developed a robust, reusable baboon model of CPB. Blood samples were obtained from adult baboons at six time intervals before, during, and after 60 minutes of partial CPB at 37 degrees C with peripheral cannulas. Both membrane (n = 7) and bubble oxygenators (n = 7) were investigated. We measured platelet and white blood cell counts; platelet response to adenosine diphosphate and release of beta-thromboglobulin; fibrinopeptide A, prothrombin fragment F1.2, thrombin-antithrombin complex, D-dimer, and plasmin-antiplasmin complex; activated complement (C3b/c and C4b/c); elastase-alpha1 proteinase inhibitor complex; and bleeding times. Adherent glycoprotein IIIa antigen in Triton X-100 washes of the perfusion circuit was also measured. Markers of baboon platelet, complement, and neutrophil activation and thrombosis significantly increased during CPB with bubble oxygenator systems but did not change appreciably in membrane oxygenator circuits. Markers of fibrinolysis, D-dimer, and plasmin-antiplasmin complex did not change with either oxygenator. The baboon model of CPB, when a bubble oxygenator is used, is a robust, reusable animal model for evaluating inhibitors of platelet, complement, and neutrophil activation and thrombosis during and after CPB.