Technologies for global health Howitt, Peter, MA; Darzi, Ara, Prof; Yang, Guang-Zhong, Prof ...
The Lancet (British edition),
08/2012, Volume:
380, Issue:
9840
Journal Article
Peer reviewed
Mechanical ventilation and intravenous sedation were initiated. Because of continuing spasms, intrathecal baclofen (1200 µg per day) was started on day 3 with a good clinical response. No ...recommendations about tetanus prophylaxis procedures for wound man agement in patients with blood diseases are available, except for bone-marrow transplantation.
Beating-heart on-pump coronary artery bypass grafting (BH-ONCAB) offers a hybrid coronary revascularization technique that may confer the benefits of an "off-pump" operation while maintaining the ...hemodynamic stability and mechanical support of conventional on-pump CABG (C-ONCAB). This study aimed to identify whether BH-ONCAB confers a morbidity or mortality benefit over C-ONCAB in the immediate and midterm postoperative period.
A systematic literature review identified 13 studies incorporating 3,930 patients (937 BH-ONCAB; 2,993 C-ONCAB) fulfilling our inclusion criteria. Outcomes were meta-analyzed using random-effects modelling. Between-study heterogeneity was investigated through quality assessment, subgroup, and risk of bias analysis.
No difference was seen in overall 30-day mortality (13 studies; odds ratio, 0.60; 95% confidence interval, 0.32 to 1.14; p = 0.12), or midterm survival (5 studies; hazard ratio, 0.65; 95% confidence interval, 0.22 to 1.88; p = 0.43) between BH-ONCAB and C-ONCAB. BH-ONCAB was associated with significantly fewer postoperative myocardial infarction events (odds ratio, 0.32; 95% confidence interval, 0.11 to 0.92; p = 0.03); however, no significant difference was observed in other postoperative morbidity outcomes. Intraoperatively, BH-ONCAB resulted in significantly less intraaortic balloon pump use, shorter cardiopulmonary bypass time, and less blood loss. The number of anastomoses and vessels grafted were not significantly different between BH-ONCAB and C-ONCAB.
BH-ONCAB is a safe and comparable alternative to C-ONCAB in terms of early mortality and late survival. Furthermore, BH-ONCAB may confer a particular advantage in preventing perioperative myocardial infarction and reducing overall blood loss. Future work should focus on larger matched studies and multicenter randomized controlled trials that risk-stratify patients according to preoperative ventricular function and renal insufficiency to allow us to optimize our surgical revascularization strategy in these high-risk patients.
Early outcomes for off-pump coronary artery bypass grafting (OPCAB) have been extensively compared with on-pump coronary revascularization (ONCAB); however, the long-term effects of OPCAB continue to ...be debated. This study aims to compare the mid-term (>1year; ≤5 years) and long-term (>5 years) survival and major adverse cardiovascular and cerebrovascular events of OPCAB versus ONCAB.
A systematic search identified 32 studies meeting our inclusion criteria. These were analyzed using random effects modeling, with subgroup evaluation according to study type. Primary outcomes were mid- and long-term survival over a follow-up period greater than 1 year. Secondary outcomes were mid- and long-term events including repeat revascularization, myocardial infarction, angina, heart failure, and cerebrovascular accidents.
Off-pump coronary artery bypass grafting confers similar overall mid-term survival when compared with ONCAB (hazard ratio, 1.06; 95% confidence interval, 0.95 to 1.19; p=0.31). On-pump coronary artery bypass grafting was associated with a significant trend towards a long-term survival advantage (hazard ratio, 1.06; 95% confidence interval, 1.00 to 1.13; p=0.05); however, this was no longer present when subgroup analysis of only randomized controlled trials, registry-based studies, and propensity-matched studies was performed. There was an increase in angina recurrence among two studies after OPCAB, but no difference was seen in 11 other studies reporting data as odds ratio. No significant differences were observed in other secondary outcomes.
This analysis demonstrates comparable mid-term mortality and mid- to long-term morbidity between OPCAB and ONCAB. On-pump coronary artery bypass grafting may be associated with improved long-term survival when all study types are analyzed; however, analysis of only randomized controlled trials and propensity-matched studies demonstrates comparable long-term mortality between OPCAB and ONCAB.
Minimally invasive and robotic coronary revascularization strategies offer less pain, fewer adverse events, better cosmesis, and speedier recovery. These procedures are vulnerable to left internal ...mammary artery (LIMA) injury that may require a full sternotomy, which eliminates the benefits of minimally invasive procedures. We present a management protocol to avoid conversion to sternotomy in minimally invasive cases based on the location of the LIMA injury at proximal, mid, and distal locations. By applying axillary bypass, LIMA extension, and repair over a shunt approaches, our protocol can be used as a successful bailout to LIMA damage in minimally invasive coronary cases.
The aim of this study was to evaluate the long-term profile and determine the factors that would influence the effect and rate of ventricular mass regression with time after aortic valve replacement ...with a stentless or a homograft valve.
We studied 300 patients during a 10-year period with at least a year of follow-up with a total of 1,273 serial echocardiographic measurements. Left ventricular mass was calculated from M-mode recordings and indexed to body surface area. Longitudinal data analysis was performed using a linear mixed effects model.
The mean age (+/- standard deviation) was 65 (+/-14) years, consisting of 216 (72%) males. A stentless valve was implanted in 156 (52%), and a homograft in 144 (48%). The median time (interquartile range) to follow-up was 4.7 (2.8 to 6.6) years. The greatest rate of left ventricular mass regression occurred in the first year after surgery. On multivariable modeling, independent predictors of left ventricular mass were valve size (p = 0.011), left ventricular function (moderate impairment, p = 0.418; severe impairment, p = 0.011), and baseline left ventricular mass (middle tercile, p < 0.001; highest tercile, p < 0.001). Only baseline ventricular mass influenced the rate of subsequent left ventricular mass regression; the greatest rate of regression occurred in patients with the highest baseline values of ventricular mass (p < 0.001).
The greatest rate of left ventricular mass regression occurs in the first year with baseline left ventricular mass as the strongest predictor and the only identified variable that influenced the rate of left ventricular mass regression.
The relative efficacy of off-pump and on-pump coronary revascularization is uncertain. A complication of off-pump surgery which is rarely considered is intraoperative conversion to cardiopulmonary ...bypass. Consequently, meta-analysis was performed of studies comparing morbidity after converted and nonconverted off-pump coronary revascularization. There were significant increases in the likelihood of stroke, myocardial injury, bleeding, renal failure, wound infection, intraaortic balloon pump requirement, transfusion, and respiratory and gastrointestinal complications after conversion. The underlying mechanisms need to be urgently elucidated. Prevention and treatment protocols for conversion warrant serious consideration and the risk of conversion may need to be discussed when obtaining informed patient consent.
Abstract Background Obesity is a complex multifactorial condition for which the treatment needs to be tailored to the individual patient. Cognitive behavioural therapy (CBT) is the mainstay for most ...obesity treatments. Obesity has been compared with addictive behaviours in which people show characteristics of dysfunctional impulsivity, which manifest as deficits in inhibitory control. We aimed to examine the effect of CBT on the objective behavioural manifestations of impulsivity during weight loss in obese adolescents. Methods 31 obese adolescents (21 boys, 17 girls) with a mean age of 14·0 years (SD 0·3) and a body-mass index (BMI) of 33·6 kg/m2 (0·9) attending an obesity camp were tested for impulsivity with the CANTAB (Cambridge, UK; Cambridge Cognition) Stop Signal Task. Tasks were undertaken before the CBT intervention, 6 weeks after the intervention (range 3–8 weeks), and at 6 month follow-up. The inclusion criteria were being obese when adjusted for age and sex, having had regular education up to GCSE level (at age 15–16 years), and being aged between 11 and 17 years. We excluded patients with a formal diagnosis of attention deficit hyperactivity disorder or an eating disorder, those receiving antipsychotic drugs, and those with a serious physical disability restricting physical activity. Findings Mean BMI fell from 33·60 kg/m2 (SD 5·0; n=31) before camp to 30·94 kg/m2 (4·5; n=31) at the end of camp (p=0·01). At 6 month follow-up, participants' weight loss had plateaued, with a mean BMI of 31·27 kg/m2 (SD 5·0; n=12, p=0·04). Reduction in impulsivity after the intervention remained when age and length of stay in camp were controlled for with a general linear model (23·9 ms 86·45; p=0·03). Impulsivity measurements were available in 26 of 31 adolescents at the end of camp. Reasons for loss to follow-up were being unwell (n=1) on the day of data collection and leaving camp for the day (n=4). Loss to follow-up was accounted for in the statistical analysis by use of a complete case analysis of all available covariates. Correlations showed a positive relation between length of stay in camp and reduction in stop signal reaction time (SSRT; r2 =0·20, p=0·03), whereas we noted an inverse relation between age and reduction in SSRT (F=7·723, p=0·011). At 6 months, 12 of 31 adolescents were followed up. In these patients, impulsivity scores decreased by a mean of 108·45 ms (SD 95·7; p=0·008) compared with baseline values. At 6 months, general linear regression did not show any significant associations; however, impulsivity scores were weakly associated with a reduction in BMI (r2 =0·139; p=0·061). Interpretation Impulsivity is an automatic behaviour pattern, thought to be stable over time. We showed that the stop signal task—a commonly used method to measure impulsivity—can be modified over time. Existing data suggest that impulsive individuals are more likely to be obese, but our data suggest that impulsivity might also be associated with weight loss and its maintenance. Limitations of the study include the before and after design in which participants could become familiar with the SSRT task, which could account for the improved scores after camp. We did not measure the intellectual ability of participants, which could be a confounding factor. The follow-up environments were also uncontrolled. This study further contributes to research of obesity based on an addictive behaviour model and treatment implications. Funding None.
Training in endovascular intervention ultimately aims to produce interventionalists who demonstrate competence in technical skills. Herein, the authors investigate the rationale for simulation-based ...training by providing an overview of the psychological theories underpinning acquisition of technical skills, training and assessment history, recent advances in simulation technology, and a critical appraisal of their role in training and assessment in endovascular intervention. Simulators have potential for training and assessment and promise solution to many shortcomings of traditional 'apprenticeship' training models. Before inclusion into the curriculum, further work is needed regarding fidelity, validity, reliability, and design of simulators to ensure accurate transfer of acquired endovascular skills from simulator to patient.
Isolation of the left subclavian artery is a rare aortic arch anomaly in which the artery originates from the pulmonary artery through a ductus arteriosus rather than the aorta. In neonates it is ...usually diagnosed incidentally with other aortic or cardiac anomalies and can be associated with chromosomal deletions. We describe an extremely rare presentation whereby subclavian artery isolation was presented with left arm ischemia in a 6-day-old child. There were also a concurrent right aortic arch, ventricular septal defect, persistent left superior vena cava, and both radial and ulnar artery hypoplasia. A family history of aortic arch anomalies with no known chromosomal aberration was also present, whereby all the male family members on the maternal side had undergone aorto-cardiac surgery as neonates. Diagnosis and surgical management are discussed.
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