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Journal and News Scan
This is an interesting opinion piece about misplaced fears on the part of physicians and patients/families regarding the dangers of radiation exposure as part of diagnostic imaging.
To illustrate the potential need for regional quality improvement efforts in thoracic surgery, the authors conducted a study of lung resection in Washington state using a discharge database including nearly 8,500 pts over a 12-year period. Inpatient mortality decreased over time but there was no change in the incidence of prolonged length of stay. Costs increased over time. Hospitals were widely distributed into categories including fewer deaths/lower costs, fewer deaths/higher costs, more deaths/lower costs, and more deaths/higher costs. The data illustrate ample opportunity for improving quality and value modeled on hospitals with fewer deaths/lower costs.
Neuroprotection strategies during deep hypothermic circulatory arrest (DHCA) in infants undergoing cardiac surgery are varied. This single institution retrospective study compared uninterrupted DHCA (24 pts) to DHCA with intermittent perfusion (16 pts). Total DHCA duration did not predict neurodevelopmental outcomes at 24 mos of age. Intermittent perfusion was associated with similar outcomes to uninterrupted DHCA despite the longer exposure to DHCA in this group. Outcomes were related to important comorbidites, length of stay and ICU stay, and multiple procedures requiring DHCA.
The timing of repair of blunt aortic injury in patients with concomitant traumatic brain injury is controversial. This single institution retrospective review analyzed outcomes in 75 pts with blunt aortic injury and traumatic brain injury, comparing early repair (<24 hrs after admission) to delayed repair. Pts undergoing early repair suffered worsening of traumatic brain injury regardless of whether repair was open or endovascular, whereas delayed repair pts did not suffer progression of traumatic brain injury. Early repair was also associated with increased morbidity and mortality.
The PARTNER trial reported reduced mortality in pts with prior CABG who underwent surgical AVR compared to TAVR. This study further explores the 288 pts in these two groups. The groups were similar in their clinical presentation and had similar instances of procedure-related mortality, stroke, and MI. The TAVR pts had more paravalvular leak, at 2 years trended towards higher all-cause mortality, experienced more rehospitalizations, and had higher rates of mortality associated with death/rehospitalization and death/stroke. Outcomes in pts with prior CABG were better after surgical AVR than after TAVR, the causes for which are not completely understood.
Good news for lovers of dark chocolate. In this randomized study of 20 pts with peripheral arterial disease, walking distance and maximal walking time were evaluated 2 hr after ingestion of either dark chocolate or milk chocolate in a cross-over design. Dark chocolate ingestion was associated with an 11% increase in distance and a 15% increase in time, likely related to NOX2 regulation. No such changes were evident in subjects ingesting milk chocolate.
Destruction of the intervalvular fibrosa (IVF) in infective endocarditis makes radical debridement followed by reconstruction of the IVF as the best treatment available for these patients. Authors describe their techniques in dealing with these extremely challenging cases, and show their results. At Cleveland Clinic, operations requiring reconstruction of the IVF are referred to as ‘Commando operations’, an indicator of the procedure's challenges.
This single institution retrospective study compared outcomes for lobectomy and segmentectomy using propensity score matching. For 312 pts in each group, there was no difference in logoregional or overall recurrence rates. Operative mortality rates were similar for segmentectomy and lobectomy (1.2% vs 2.5%). 5-year surival rates were also similar (54% vs 60%).
This randomized trial of high risk patients with small clinial stage I cancers randomized pts to sublobar resection with or without adjuvant brachytherapy. The median follow-up for 222 pts was 4.4 years. 3 year survival was identical (71%) between the groups. There was no difference in time to local recurrence. Brachytherapy did not significantly reduce the incidence of local recurrence, even in patients with close or involved margins.
In this randomized trial involving195 pts from 30 centers, pts underwent chemoradiotherapy followed by surgery or surgery alone for stage I or II esophageal cancer. The median follow-up was 94 months. 80% of pts had clinical stage II disease. R0 resection rate and 3-year survival were similar between the groups. Induction therapy was associated with an increase in operative mortality (11.1% vs 3.4%, p=0.049).