This article provides an update for 2015 on the burden of cardiovascular disease (CVD), with a particular focus on coronary heart disease (CHD) and stroke, across the countries of Europe. ...Cardiovascular disease is still the most common cause of death within Europe, causing almost two times as many deaths as cancer across the continent. Although there is clear evidence, where data are available, that mortality from CHD and stroke has decreased substantially over the last 5-10 years, there are still large inequalities found between European countries, in both current rates of death and the rate at which these decreases have occurred. Similarly, rates of treatment, particularly surgical intervention, differ widely between those countries for which data are available, indicating a range of inequalities between them. This is also the first time in the series that we use the 2013 European Standard Population (ESP) to calculate age-standardized death rates (ASDRs). This new standard results in ASDRs around two times as large as the 1976 ESP for CVD conditions such as CHD but changes little the relative rankings of countries according to ASDR.
Our study describes and analyses the results from aortopexy for the treatment of airway malacia in children.
Demographic data, characteristics and preoperative, operative and outcome details, ...including the need for reintervention, were collected for children undergoing aortopexy between 2006 and 2016.
One hundred patients median age 8.2 months, interquartile range (IQR) 3.3-26.0 months underwent aortopexy. Sixty-four (64%) patients had tracheomalacia (TM) only, 24 (24%) patients had TM extending into their bronchus (tracheobronchomalacia) and 11 (11%) patients had bronchomalacia. Forty-one (41%) children had gastro-oesophageal reflux disease, of which 17 (41%) children underwent a Nissen fundoplication. Twenty-eight (28%) children underwent a tracheo-oesophageal fistula repair prior to aortopexy (median 5.7 months, IQR 2.9-17.6 months). The median duration of follow-up was 5.3 years (IQR 2.9-7.5 years). Thirty-five (35%) patients were on mechanical ventilatory support before aortopexy. Twenty-seven (77%) patients could be safely weaned from ventilator support during the same admission after aortopexy (median 2 days, IQR 0-3 days). Fourteen patients required reintervention. Overall mortality was 16%. Multivariable analysis revealed preoperative ventilation (P = 0.004) and bronchial involvement (P = 0.004) to be adverse predictors of survival. Only bronchial involvement was a predictor for reintervention (P = 0.012).
Aortopexy appears to be an effective procedure in the treatment of children with severe airway malacia. Bronchial involvement is associated with adverse outcome, and other procedures could be more suitable. For the treatment of severe airway malacia with isolated airway compression, we currently recommend aortopexy to be considered.
Purpose
To determine the effects of the sodium content of maintenance fluid therapy on cumulative fluid balance and electrolyte disorders.
Methods
We performed a randomized controlled trial of adults ...undergoing major thoracic surgery, randomly assigned (1:1) to receive maintenance fluids containing 154 mmol/L (Na154) or 54 mmol/L (Na54) of sodium from the start of surgery until their discharge from the ICU, the occurrence of a serious adverse event or the third postoperative day at the latest. Investigators, caregivers and patients were blinded to the treatment. Primary outcome was cumulative fluid balance. Electrolyte disturbances were assessed as secondary endpoints, different adverse events and physiological markers as safety and exploratory endpoints.
Findings
We randomly assigned 70 patients; primary outcome data were available for 33 and 34 patients in the Na54 and Na154 treatment arms, respectively. Estimated cumulative fluid balance at 72 h was 1369 mL (95% CI 601–2137) more positive in the Na154 arm (
p
< 0.001), despite comparable non-study fluid sources. Hyponatremia < 135 mmol/L was encountered in four patients (11.8%) under Na54 compared to none under Na154 (
p
= 0.04), but there was no significantly more hyponatremia < 130 mmol/L (1 versus 0;
p
= 0.31). There was more hyperchloremia > 109 mmol/L under Na154 (24/35 patients, 68.6%) than under Na54 (4/34 patients, 11.8%) (
p
< 0.001). The treating clinicians discontinued the study due to clinical or radiographic fluid overload in six patients receiving Na154 compared to one patient under Na54 (excess risk 14.2%; 95% CI − 0.2–30.4%,
p
= 0.05).
Conclusions
In adult surgical patients, sodium-rich maintenance solutions were associated with a more positive cumulative fluid balance and hyperchloremia; hypotonic fluids were associated with mild and asymptomatic hyponatremia.
Objective To compare the efficacy and adverse effects of using bronchial blockers (BBs) and double-lumen endobronchial tubes (DLTs). Design Systematic review and meta-analysis of randomized ...controlled trials (RCTs) comparing BBs and DLTs. Setting Hospital units undertaking thoracic surgery Participants Patients undergoing thoracic surgery requiring lung isolation. Interventions BBs and DLTs. Measurements and Main Results A systematic literature search was conducted for RCTs comparing BBs and DLTs using Google Scholar, Ovid Medline, and Cochrane library databases up to October 2013. Inclusion criteria were RCTs comparing BBs and DLTs, intubation carried out by qualified anesthesiologists or trainee specialists, outcome measures relating to either efficacy or adverse effects. Studies that were inaccessible in English were excluded. Mantel-Haenszel fixed-effect meta-analysis of recurring outcome measures was performed using RevMan 5 software. The search produced 39 RCTs published between 1996 and 2013. DLTs were quicker to place (mean difference: 51 seconds, 95% confidence intervals CI 8-94 seconds; p = 0.02) and less likely to be incorrectly positioned (odds ratio OR 2.70; 95% CI 1.18-6.18, p = 0.02) than BBs. BBs were associated with fewer patients having a postoperative sore throat (OR 0.39, 95% CI: 0.23-0.68, p = 0.0009), less hoarseness (OR: 0.43,95%, CI 0.24-0.75, p = 0.003), and fewer airway injuries (OR 0.40, 95% CI 0.21-0.75, p = 0.005) than DLTs. Conclusion While BBs are associated with a lower incidence of airway injury and a lower severity of injury, DLTs can be placed quicker and more reliably.
Ischaemic spinal cord injury (SCI) remains the Achilles heel of open and endovascular descending thoracic and thoracoabdominal repair. Neurological outcomes have improved coincidentially with the ...introduction of neuroprotective measures. However, SCI (paraplegia and paraparesis) remains the most devastating complication. The aim of this position paper is to provide physicians with broad information regarding spinal cord blood supply, to share strategies for shortening intraprocedural spinal cord ischaemia and to increase spinal cord tolerance to transitory ischaemia through detection of ischaemia and augmentation of spinal cord blood perfusion. This study is meant to support physicians caring for patients in need of any kind of thoracic or thoracoabdominal aortic repair in decision-making algorithms in order to understand, prevent or reverse ischaemic SCI. Information has been extracted from focused publications available in the PubMed database, which are cohort studies, experimental research reports, case reports, reviews, short series and meta-analyses. Individual chapters of this position paper were assigned and after delivery harmonized by Christian D. Etz, Ernst Weigang and Martin Czerny. Consequently, further writing assignments were distributed within the group and delivered in August 2014. The final version was submitted to the EJCTS for review in September 2014.
The Centers for Medicare & Medicaid Services added lung cancer screening with low-dose computed tomography (LDCT) as a Medicare preventive service benefit in 2015 following findings from the National ...Lung Screening Trial (NLST) that showed a 16% reduction in lung cancer mortality associated with LDCT. A challenge in developing and promoting a national lung cancer screening program is the high false-positive rate of LDCT because abnormal findings from thoracic imaging often trigger subsequent invasive diagnostic procedures and could lead to postprocedural complications.
To determine the complication rates and downstream medical costs associated with invasive diagnostic procedures performed for identification of lung abnormalities in the community setting.
A retrospective cohort study of non-protocol-driven community practices captured in MarketScan Commercial Claims & Encounters and Medicare supplemental databases was conducted. A nationally representative sample of 344 510 patients aged 55 to 77 years who underwent invasive diagnostic procedures between 2008 and 2013 was included.
One-year complication rates were calculated for 4 groups of invasive diagnostic procedures. The complication rates and costs were further stratified by age group.
Of the 344 510 individuals aged 55 to 77 years included in the study, 174 702 comprised the study group (109 363 62.6% women) and 169 808 served as the control group (106 007 62.4% women). The estimated complication rate was 22.2% (95% CI, 21.7%-22.7%) for individuals in the young age group and 23.8% (95% CI, 23.0%-24.6%) for those in the Medicare group; the rates were approximately twice as high as those reported in the NLST (9.8% and 8.5%, respectively). The mean incremental complication costs were $6320 (95% CI, $5863-$6777) for minor complications to $56 845 (95% CI, $47 953-$65 737) for major complications.
The rates of complications after invasive diagnostic procedures were higher than the rates reported in clinical trials. Physicians and patients should be aware of the potential risks of subsequent adverse events and their high downstream costs in the shared decision-making process.
Thoracic surgical procedures are associated with an increased risk of postoperative pulmonary complications (PPCs), which seem to be related directly to intraoperative driving pressure. The authors ...conducted this study to describe the incidence of PPCs in patients in whom an individualized open-lung approach was applied during one-lung ventilation.
This was a prospective, multicenter, national descriptive study.
Thoracic surgery patients undergoing one-lung ventilation.
Eligible participants were included consecutively from October 1, 2016, to September 30, 2017. A total of 690 patients were included.
An individualized open-lung approach that consisted of an alveolar recruitment maneuver followed by a positive end-expiratory pressure adjusted to best respiratory system compliance was performed in all patients.
Preoperative and intraoperative data were recorded; the primary outcome was a description of the incidence of PPCs in these patients during the first 7 postoperative days. The patients were mainly male, and half of them had a high risk of PPCs (ARISCAT score exceeding 44). Eleven percent of participants developed a PPC within the first postoperative week. The mean open lung positive end-expiratory pressure was 8 ± 3 cmH2O. When compared with pre-open lung approach values, the open-lung approach significantly decreased the driving pressure (14 ± 4 cmH2O v 11 ± 3 cmH2O; p < 0.001) and increased dynamic compliance (30 ± 10 mL/cmH2O v 43 ±15 mL/cmH2O; p < 0.001).
The low incidence of PPCs in patients who underwent an open-lung approach during one-lung ventilation compared with that reported for other thoracic surgery series and the decrease in the driving pressure in these patients justify an additional randomized controlled trial to compare the open-lung approach with the standard protective strategy of low tidal volume and low positive end-expiratory pressure.
Abstract Objective We changed our surgical approach to malignant pleural mesothelioma (MPM) in August 2011 and adopted pleurectomy and decortication (PD) instead of extrapleural pneumonectomy (EPP). ...In this study, we analyzed our perioperative and survival results during the 2 periods. Methods All patients who underwent surgical intervention for MPM during 2003-2014 were included. Data were retrospectively analyzed from a prospective database. Before August 2011, patients underwent evaluation for EPP and adjuvant chemoradiation (group 1). After August 2011, patients were evaluated for PD and adjuvant chemotherapy and/or radiation (group 2). Demographic characteristics, surgical technique, histology, side, completeness of resection, and types of treatments were recorded. Statistics was performed using Student t test, χ2 tests, uni- and multivariate regression, and Kaplan-Meier survival analysis. Results The same surgical team operated on 130 patients. Median age was 55.7 years (range, 26-80 years) and 76 were men. EPP and extended PD was performed in 72 patients. Ninety-day mortality was 10%. Median survival was 17.8 months with a 5-year survival rate of 14%. Uni- and multivariate analyses showed that epithelioid histology, stage N0, and trimodality treatment were associated with better survival ( P = .039, P = .012, and P < .001, respectively). Demographic variables and overall survival (15.6 vs 19.6 months, respectively) were similar between the groups, whereas nonepithelioid histology, use of preoperative chemotherapy, and incomplete resections were more frequent in group 2 ( P < .001, P < .001, and P = .006, respectively). Follow-up was shorter in group 2 (22.5 ± 20.6 vs 16.4 ± 10.9 months; P < .001). Conclusions Adoption of PD as the main surgical approach is not associated with survival disadvantage in the surgical treatment of MPM.
Fifty-eight percent of women in science, engineering, and medicine report being affected by sexual harassment (SH). This study sought to determine the extent of SH in cardiothoracic surgery.
The ...study developed a survey that was based on the Sexual Experience Questionnaire-Workplace, physician wellness, and burnout surveys. The survey was open to responses for 45 days and was disseminated through The Society of Thoracic Surgeons, Women in Thoracic Surgery, and Thoracic Surgery Residents Association listservs. A reminder email was issued at 28 days. Student t tests, Fisher exact tests, and χ
tests were used to compare results.
Of 790 respondents, 75% were male and 82% were attending surgeons. A total of 81% of female surgeons vs 46% of male attending surgeons experienced SH (P < .001). SH also was reported by trainees (90% female vs 32% male; P < .001). According to women, the most common offenders were supervising leaders and colleagues; for men, it was ancillary staff and colleagues. Respondents reported SH at all levels of training. A total of 75% of women surgeons vs 51% of men surgeons witnessed a colleague be subjected to SH; 89% of respondents reported the victim as female (male 2%, both 9%; P < .001). A total of 49% of female witnesses (50% of male witnesses) reported no intervention; less than 5% of respondents reported the offender to a governing board. SH was positively associated with burnout.
SH is present in cardiothoracic surgery among faculty and trainees. Although women surgeons are more commonly affected, male surgeons also are subjected to SH. Despite witnessed events, intervention currently is limited. Policies, safeguards, and bystander training should be instituted to decrease these events.
PDF
