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Journal and News Scan
In an editorial relating to a published meta-analysis ( Heart doi:10.1136/heartjnl-2013-304262), Hawkes raises the thorny but all too often repeated issue of research fraud. He estimates that in the UK, many deaths may be related to the recommendations regarding the use of β blockers during surgery, based mainly on a study by a now discredited researcher from Holland. There have been many recent and highly publicised instances of research fraud, leading to retractions of multiple peer reviewed papers, potentially impacting on our day to day clinical practice.
This updated meta-analysis comparing bilateral internal mammary artery (BIMA) versus left internal mammary artery (LIMA) for coronary artery bypass grafting includes 27 observational studies and over 79,000 patients and demonstrates an increased long-term survival in patients receiving a BIMA operation versus a LIMA operation.
With increasing access to online information, patients who have seen their purchasing ability decrease or have been turned down by insurance companies are increasingly turning to medical tourism as a realistic option. The article profiles patients such as Michael Shopenn who went to Belgium for his hip replacement. Implications for increasing price transparency, access and quality for patients are also touched upon in this insightful piece.
In a remarkable large prospective study conducted in the Netherlands, patients who underwent balloon angioplasty alone in the late 1980s were followed for a median of 19.5 years. Of the total 806 patients, 287 persistent smokers after percutaneous coronoary intervention (PCI) were compared to 210 patients who quit smoking after PCI. Those who quit had at least 2.1 years life-expectancy gained compared to persistent smokers. The findings of this study reinforce the notion that interventions can be an opportunity for behavior modifications that can translate into survival benefits.
This retrospective review evaluated combined carotid endarterectomy (CEA) and open heart surgery (OHS), staged CEA and OHS, or OHS combined with staged carotid artery stenting (CAS) using propensity score matching. Staged CAS-OHS and combined CEA-OHS had similar initial outcomes that were better than staged CEA-OHS owing to an increased risk of MI in the latter group. Staged CAS-OHS had better long-term outcomes compared to staged CEA-OHS and combined CEA-OHS. Overall, short-term and long-term outcomes appear to favor staged CAS-OHS.
This issue focuses on total arterial revascularization, including BIMA vs LIMA, mid-term outcomes for RA vs SVG, and totally endoscopic CABGs.
Technical performance in congenital heart surgery, as judged by discharge electrocardiogram and other clinical factors, is associated with postoperative complications including mortality. This study assessed technical performance related to long-term survival in nearly 700 patients. After controlling for risk category and patient age, poor technical performance was found in multivariable analysis to be strongly related to late mortality and the need for late reintervention.
This retrospective single center study assessed the efects of transfusion on outcomes after aortic valve replacement in over 1300 patients. Long-term survival was unaffected by transfusion of red blood cells or platelets. However, transfusion of plasma was associated with a modest but significant decrease in long-term survival.
Optimal therapy (surgery vs multimodality therapy) for clinical T2N0 esophageal cancer is controversial. This STS Database review assessed accuracy of clinical staging compared to pathologic staging in nearly 500 patients who underwent initial resection. T2N0 was confirmed in 27%, 26% were downstaged, and 47% were upstaged. The most common cause for upstaging was nodal involvement without change in T status. In another group of clinical T2N0 patients who underwent induction therapy, upstaging was evident in the resection specimen in 38%.
In this multi-institutional prospective trial, 400 pts at increased risk for pulmonary complications after major abdominal surgery were randomized to standard intraoperative ventilator management and lung-protective management with low tidal volumes and PEEP. A composite of pulmonary and extrapulmonary complications occurred in 27.5% of the control group compared to 10.5% of the treatment group at 7 days. The incidence of respiratory failure was 17% in the control group and 5% in the treatment group. The treatment group length of stay was 2.5 days shorter.