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Journal and News Scan
This joint statement regarding patient safety advocates a variety of systems to improve outcomes, including checklists, preoperative briefings, postoperative debriefings, and training in communication skills. Nontechnical skills are the key to improvements in safety. Anonymous event reporting and regular training in rare but significant events are also recommended.
Process improvement in cardiac surgery: Development and implementation of a reoperation for bleeding checklist
The surgical team at Cleveland Clinic have established a checklist, designed to become second nature to residents in training, for checking haemostasis after cardiac surgery. They have tested their process both in a trial mode and then in a service-wide implementation. This is an important part of establishing a plan for reduction of blood use and of re-opening for bleeding.
Meta-analysis of secure randomised controlled trials of β-blockade to prevent perioperative death in non-cardiac surgery
Bouri and collegues have analysed data from multiple trials of beta blockade prior to non-cardiac surgery. Guidelines for management have been based on these findings. However, exclusion of one report, now discredited, suggests an increase in morbidity rather than a protective effect. They note the increase in the risk of mortality, the primary end-point at 30 days of 27%. These findings indicate the need for further well controlled studies into the use of beta blockers.
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.
A meta-analysis comparing bilateral internal mammary artery with left internal mammary artery for coronary artery bypass grafting
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.
A Direct Comparison of Early and Late Outcomes with Three Approaches to Carotid Revascularization and Open Heart Surgery
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.