Is talc pleurodesis safe for young patients following primary spontaneous pneumothorax?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether talc used for pleurodesis in young patients with a spontaneous pneumothorax has any long-term adverse effects. One hundred and eighty-one papers were identified using the search below. Eight papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of the papers are tabulated. We conclude that talc pleurodesis in young patients with a spontaneous pneumothorax appears to have minimal long-term adverse consequences.     

What is the best treatment for malignant pleural effusions?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether chemical pleurodesis is superior to catheter drainage or pleuroperitoneal shunts (PPS) in the management of patients with pleural effusions. Overall 161 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that chemical pleurodesis is superior to chronic catheter drainage and PPS in terms survival length and mortality rates but in patients with trapped lung syndrome chronic intrapleural catheter placement is indicated. Six studies reported patient outcomes after treatment with chemical pleurodesis. They report high success rates (89.4%) and low mortality rates (2%) without any need to convert to open thoracotomy. Mean hospital stay of 2.33 days, complication rates of 16.5% and mean survival length of 23.8 ± 16.3 months were observed. Five studies managed malignant pleural effusions (MPEs) using chronic indwelling catheters. They reported mean survival length of 126 days. Symptomatic relief was achieved in 94.2% of patients. There was a significant reduction in the Medical Research Council dyspnoea score (3.0-1.9, P < 0.001) and despite complication rates of 22%, comparable mortality rates (7.5%) were observed. Even in patients with trapped lung syndrome, mean survival length was 125 days with symptomatic improvement being achieved in 90.9% of patients. Three studies treated MPEs using PPSs. Mean hospital stay was 6.2 days (range 2-26) with a mean survival length of 11 months. Pleurodesis success rates varied from 57.1% to 95% with a complication rate of 14.8%. PPSs were shown to produce lower success rates (57.1% vs. 92.3%), shorter survival lengths (4.3 ± 1.9 vs. 6.7 ± 2.1 months) and higher complication rates (14.3% vs. 2.8%) than talc pleurodesis. Overall, chemical pleurodesis is the optimal treatment option for MPE with use of chronic intrapleural catheters reserved in cases where talc pleurodesis is not possible.     

Does liberal use of bone wax increase the risk of mediastinitis?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether bone wax increases the risk of mediastinitis in patients undergoing cardiac surgery. Altogether 276 papers were found using the reported search, of which five presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that animal studies indicate that there are strong reasons for concern over the liberal usage of bone wax.     

Can any intervention effectively reduce the pain associated with chest drain removal?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether any intervention effectively reduces the pain associated with chest drain removal. Altogether 94 papers were found using the reported search, of which 6 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is minimal evidence for the effectiveness of a single approach to providing analgaesia for chest drain removal. Studies in the literature contain small numbers and are underpowered to address the questions they ask.     

What is the optimal dose of aspirin after discharge following coronary bypass surgery

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, what is the optimal dose of aspirin post cardiac surgery that should be given to prevent graft occlusion and prolong survival. Altogether, 114 papers were found from Medline and 59 papers were found from the Cochrane Central Register of Controlled Trials using the reported search, of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that best evidence suggests that 325 mg optimally improves vein graft survival and mortality, and does not cause an increase in complications compared to lower doses.     

Does lung cancer screening with chest X-ray improve disease-free survival?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether screening an asymptomatic person with a routine chest X-ray would detect lung cancer early and, most importantly, improve that person's disease-free survival from lung cancer. Altogether 136 papers were identified using the search below. Ten papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of the papers are tabulated. We conclude that despite methodological criticisms and concerns regarding biases inherent to screening studies, there is currently no evidence to support the use of chest X-ray to screen an asymptomatic person for lung cancer.     

Does aspirin 6 h after coronary artery bypass grafting optimise graft patency?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether aspirin given 6 h after coronary arterial bypass grafting optimises graft patency. Altogether 201 papers were found using the reported search, of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is good evidence that Aspirin given <6 h post surgery optimally reduces graft occlusion, without an increase in bleeding.     

Does off-pump coronary artery surgery reduce the incidence of postoperative atrial fibrillation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether off-pump coronary artery surgery reduces the incidence of postoperative atrial fibrillation. Altogether 107 papers were found using the reported search, of which 18 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that off-pump coronary artery surgery significantly reduces the incidence of postoperative atrial fibrillation with a number needed to treat of 20 to prevent one case of AF.     

Low dose (renal dose) dopamine in the critically ill patient

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether low dose (renal dose) dopamine in the critically ill patient prevents acute renal failure. Altogether 141 papers were found using the reported search, of which three presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is no evidence to support the use of low-dose dopamine to treat acute renal failure in critically ill patients.     

Might gene therapy offer symptomatic relief for patients with 'no option' angina?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of gene therapy could relieve angina symptoms in patients who are not amenable to conventional revascularisation strategies. Altogether 60 papers were identified using the search below. Seven papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of the papers are tabulated. We conclude that, gene therapy for ischaemic heart disease is in its infancy with evaluation trials of novel vectors, delivery methods and targeted patient population. The initial results from the randomised clinical trials using gene therapy for severe CHD are interesting but clear benefits are yet to be demonstrated. Longer term outcomes from the AGENT trial and VIVA trials are awaited.     

Is the figure-of-eight superior to the simple wire technique for closure of the sternum?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed is whether the figure-of-eight technique is superior to the simple wire technique for closing of the sternum? Altogether 111 papers were found in Medline of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that the figure-of-eight wire technique is not superior to the simple wire technique for closure of the sternum.     

Is antero-posterior position superior to antero-lateral position for placement of electrodes for external cardioversion of atrial fibrillation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the antero-posterior position is superior to the antero-lateral position for the placement of electrodes for cardioversion of atrial fibrillation. Altogether 167 papers were found using the reported search, of which 5 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is no clinical difference between the two positions although if one position fails to convert the patient, the alternative position may still achieve success.     

Does the radial artery provide better long-term patency than the saphenous vein?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the radial artery provides better long-term patency than the saphenous vein. Altogether 379 papers were found using the reported search, of which 12 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We concluded that there is evidence that radial artery grafts have a higher rate of patency than saphenous vein grafts. Surgeons can confidently use the radial artery as a second arterial bypass graft, particularly in patients with severe native-vessel stenosis.     

In aortic arch surgery is there any benefit in using antegrade cerebral perfusion or retrograde cerebral perfusion as an adjunct to hypothermic circulatory arrest?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether patients having aortic arch surgery benefit from antegrade or retrograde cerebral perfusion in addition to hypothermic circulatory arrest to reduce neurological injury or mortality. Altogether 408 papers were found using the reported search, of which 16 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that antegrade cerebral perfusion is superior as an adjunct to hypothermic circulatory arrest when compared to retrograde cerebral perfusion or hypothermic circulatory arrest alone, although clinical evidence for this from prospective clinical trials is weak.     

Which patients would benefit from an intra-aortic balloon pump prior to cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether there is a group of patients who would benefit from a prophylactic intra-aortic balloon pump prior to cardiac surgery. Altogether 110 papers were found using the reported search, of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is evidence to support preoperative intra-aortic balloon pump insertion in patients with two of left ventricular ejection factor <30 or 40%, left main stem disease, unstable angina or redo-operation.     

Does lung cancer screening with low-dose computerised tomography (LDCT) improve disease-free survival?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether screening an asymptomatic person with a low-dose computerised tomography (LDCT) would detect lung cancer early and most importantly improve that person's disease-free survival from lung cancer. Altogether 354 papers were identified using the search below. Ten papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of the papers are tabulated. We conclude that the current observational and prevalence studies on the role of LDCT screening has failed to establish whether LDCT really impacts on improved disease-free survival, despite consistently higher early detection rates of lung cancer.     

Is haloperidol or a benzodiazepine the safest treatment for acute psychosis in the critically ill patient?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether haloperidol or a benzodiazepine is the safest treatment for acute psychosis in the critically ill patient. Altogether 294 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that haloperidol should be considered the first line drug for agitated patients post cardiac surgery, however lorazepam either alone or in conjunction with haloperidol is an acceptable alternative.     

What is the optimal medical treatment for stable cardiac surgical patients who go into atrial fibrillation after their operation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was which medical strategy is the optimal treatment for stable patients going into atrial fibrillation post cardiac surgery. Altogether 281 papers were found from medline and 83 from the Cochrane Central Register of Controlled Trials using the reported search, of which 12 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is very little evidence to support any one strategy over another.     

In patients post cardiac surgery do high doses of protamine cause increased bleeding?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether high doses of protamine causes increased bleeding in patients post cardiac surgery. Altogether 268 papers were found using the reported search, of which five presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that high doses of protamine can cause increased bleeding and impaired platelet function but these effects have never been demonstrated below a ratio of 2.6:1 protamine to heparin.     

Can cardiac troponins be used to diagnose a perioperative myocardial infarction post cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether Troponin I or T can effectively diagnose a perioperative myocardial infarction after cardiac surgery. Altogether 191 papers were found using the reported search, of which 17 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that Troponin I and T can both be used to indicate myocardial damage, with the level correlating well with the level of injury. However until issues such as a 'gold standard' for peri-operative MI are addressed, one single cut-off point cannot be recommended for either test.