Aortic aneurysm in a 74-year-old man with coronary disease and obstructive lung disease: is double jeopardy enough?

A previous decision analysis examined a patient with severe CAD, diminished ventricular function, and an abdominal aortic aneurysm and also concluded that CABG followed by aneurysm repair was optimal. This patient, who had well-preserved cardiac function but severely compromised pulmonary status, stood to gain less from CABG than would a patient with more severe coronary disease, thus accounting for the "close-call" between the CABG-AAA and AAA only strategies. Nevertheless, the analysis did emphasize the benefit of aneurysm repair, whether done alone or after CABG. The analysis also highlighted the significant risk of aneurysm rupture the patient is exposed to while recovering from CABG surgery. The operative mortality risks of the two procedures are similar; thus, the patient's total operative risk is approximately doubled if he undergoes both procedures rather than aneurysm repair alone. The key question raised by the analysis is whether this double jeopardy is more than compensated by the degree to which prior CABG reduces both short-term cardiac risk at subsequent aneurysm repair and long-term cardiac mortality. For this patient, who had good cardiac function, the gains appeared sufficient to offset the interval risk of aneurysm rupture and the additional risk associated with a surgical procedures. THE REAL WORLD The patient indeed underwent and tolerated CABG, although he had a stormy prolonged postoperative course due to pulmonary failure. After discharge from the hospital, he declined readmission for repair of the aneurysm. We did not model that possibility, clearly an inadequacy in our tree. Some six months later, the patient was still alive and was, reluctantly, readmitted for aneurysmorrhaphy. At that time, however, his pulmonary function had deteriorated and both the anesthesiologist and the pulmonary consultant stated unequivocally that further surgery was now impossible. In retrospect, the expected utility of CABG without aneurysm repair (thus providing only a decrease in the long-term mortality risk from his CAD) would have been 1.95 (DEALE) or 2.06 (Markov) years. Sensitivity analysis revealed that, even if long-term cardiac risk were completely eliminated by CABG, immediate aneurysm repair would have been a better approach had the patient's physicians known he would be likely to refuse or not be a candidate for the second operation. In summary, although the patient's comorbidities did indeed place him at significant operative risk for either aneurysmorrhaphy alone or two sequential procedures, the benefits to be gained were shown to far outweigh the risks when compared with expectant observation.(ABSTRACT TRUNCATED AT 400 WORDS)     

Dietary advice for patients undergoing coronary artery bypass surgery: falling on deaf ears?

Coronary heart disease (CHD) is the most common cause of death in the UK, accounting for around 125,000 deaths per year. Diet is a CHD risk factor that is modifiable, and therefore has the potential to alter the risk for CHD. At present, little is known about the dietary patterns of CHD patients. The present study aimed to assess the effectiveness of dietary advice administered to patients undergoing coronary artery bypass grafting (CABG) surgery. Dietary intake was assessed on three occasions (pre-operatively, 2 months after surgery and 1 year after surgery) by use of a food amount frequency questionnaire that had been previously validated. Patients were also asked to provide information on any dietary advice they had received. Complete data were available for 15 males, aged 51-79 years, who were admitted for CABG surgery. The absolute mean intakes of total fat, saturated fat and dietary cholesterol significantly increased 1 year after CABG surgery by 21%, 36% and 51%, respectively, and the choice of food items reflected this change in nutrient intake. These undesirable changes occurred despite the provision of dietary advice. This may consequently increase the risk of recurrent problems, and serve to promote further atherosclerosis in the arteries of such patients. The observations highlight the need to better understand the barriers to nutritional advice and compliance seen in CABG patients.     

Triage for coronary artery bypass graft surgery in Canada: Do patients agree on who should come first?

Background  

The extent to which clinical and non-clinical factors impact on the waiting-list prioritization preferences of patients in the queue is unknown. Using a series of hypothetical scenarios, the objective of this study was to examine the extent to which clinical and non-clinical factors impacted on how patients would prioritize others relative to themselves in the coronary artery bypass surgical queue.     

Role of palliative tracheobronchial stenting in hospice patients: boon or bane?

Lung cancer is the leading cause of cancer mortality and morbidity. Patients with advanced lung cancer have distressful symptoms like dyspnea. It has severe negative impact on the quality of life. Airway stenting has become widespread for palliation of airway stenosis in patients with metastatic airways disease. Although it provides improvement in symptoms, actual survival benefit is limited with severe potential complications. Appropriate patient selection in terms of site of tumor, type of stent placement is needed to achieve maximum benefit for patients. Here we will discuss 2 patients with advanced lung cancer who received bronchial stent for intractable dyspnea. Although there was dramatic improvement in symptoms and quality of life, both died shortly. Was there any benefit of stenting remained unanswered.     

Platelet inhibitors in non-ST-segment elevation acute coronary syndromes and percutaneous coronary intervention: glycoprotein IIb/IIIa inhibitors, clopidogrel, or both?

The role of glycoprotein (Gp) IIb/IIIa receptor antagonists remains controversial and these agents are infrequently utilized during non-ST-segment elevation acute coronary syndromes (NSTE-ACS) despite American Heart Association/American College of Cardiology guidelines. Despite recommendations, the NRMI-4 (National Registry of Myocardial Infarction 4) and CRUSADE (Can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines?) registries observed that only 25%-32% of eligible patients received early Gp IIb/IIIa therapy, despite a 6.3% absolute mortality reduction in NRMI-4 and a 2% absolute mortality reduction in CRUSADE. A pooled analysis of Gp IIb/IIIa data from these registries suggest a major reduction in mortality (Odds Ratio = 0.43, 95% Confidence Index 0.25-0.74, p = 0.002) with early Gp IIb/IIIa therapy, yet clinicians fail to utilize this option in NSTE-ACS. The evidence-based approach to NSTE-ACS involves aspirin, clopidogrel, low-molecular weight heparins, or unfractionated heparin in concert with Gp IIb/Ila receptor antagonists, however, newer percutaneous coronary intervention (PCI)-based trials challenge current recommendations. Novel strategies emerging in NSTE-ACS include omitting Gp IIb/Ila inhibitors altogether or using Gp IIb/IIIa inhibitors with higher doses of clopidogrel in selected patients. The ISAR-REACT (Intracoronary stenting and antithrombotic regimen-Rapid early action for coronary treatment) and ISAR-SWEET (ISAR-Is abciximab a superior way to eliminate elevated thrombotic risk in diabetics) trials question the value of abciximab when 600 mg of clopidogrel concurrently administered during PCI. The CLEAR-PLATELETS (Clopidogrel loading with eptifibatide to arrest the reactivity of platelets) and PEACE (Platelet activity extinction in non-Q-wave MI with ASA, clopidogrel, and eptifibatide) trials suggest more durable platelet inhibition when Gp IIb/IIIa inhibitors are used with higher doses clopidogrel. The ISAR-COOL (ISAR: Cooling off strategy) trial found no difference in ischemic outcomes when Gp IIb/IIIa inhibitors were excluded and ARMYDA-2 (Antiplatelet therapy for reduction of myocardial damage during angioplasty) suggested higher doses of clopidogrel are more appropriate during PCI when Gp IIb/IIIa inhibitors are not utilized. This constellation of new trials forces reconsideration of current recommendations in regards to patient risk stratification, choice of antithrombotic therapy, doses, and timing. These new data will impact emerging guidelines and updates are currently in progress.     

Physicians and organizations: strange bedfellows or a marriage made in heaven?

Underscoring the importance of physician-organization alignment as a necessary condition for building and sustaining integrated healthcare systems, this article provides information regarding the nature of such alignment, the key influential factors, and the processes employed to make alignment a reality. Structural and strategic factors address the influence of environmental, market, and organizational characteristics on alignment. The strategic intent of organizations and physicians, and physician perspectives on the effects of integration, are explored. Key processes examined include building trust, placing physicians in management and governance, and developing physician leadership. Continuing issues and challenges are considered, and a set of principles to help guide the journey of physicians and organizations toward successful alignment is suggested.     

Active warming systems to maintain perioperative normothermia in hip replacement surgery: a therapeutic aid or a vector of infection?

Various reliable body heat-regulating systems have been designed and developed with the aim of maintaining an adequate body temperature in the course of major surgery. This is crucial to avoid the onset of potentially severe complications that are especially serious in elderly and debilitated subjects. Among these systems, the Bair Hugger blanket has demonstrated excellent efficacy. However, some reports in the literature have suggested that the use of such devices can increase the risk of nosocomial infections, particularly surgical wound infections. The aim of this study was to assess the risk of contamination of the surgical site correlated to the use of the Bair Hugger blanket during hip replacement surgery. To this end, the level of bacterial contamination of the air in the operating theatre was quantified with and without the use of the Bair Hugger, during the course of 30 total non-cemented hip implants performed in patients with osteoarthritis. Sampling was done both in the empty theatre and during surgical procedures, in different zones around the operating table and on the patient's body surface. Statistical analysis of the results demonstrated that the Bair Hugger system does not pose a real risk for nosocomial infections, whereas it does offer the advantage of preventing the potentially very severe consequences of hypothermia during major orthopaedic surgery. In addition, monitoring patients over the six months following the operation allowed us to exclude a later manifestation of a nosocomial infection.