Endovascular treatment of aortobronchial fistula secondary to coronary artery bypass graft (CABG)

Aortobronchial fistula (ABF) is a rare and late complication of cardiac surgery. If untreated, mortality rate is approximately 100% secondary to exsanguinations haemoptysis. Early diagnosis and treatment are essential for successful management. Open surgical repair is associated with high morbidity and mortality rate, ranging from 25% to 41%. Endovascular treatments of ABF is a less invasive treatment modality and have become an important alternative to open surgical intervention in aortic pathologies. We present a case of ABF that successfully is managed by endovascular approach.     

The relationship between surgical site infection and volume of coronary artery bypass graft surgeries: Taiwan experience.

In this study, the overall incidence of surgical site infection was 8.83% (3.28% for index hospitalization events [ie, events that occurred during hospitalization for surgery] and 5.55% for postdischarge events [ie, events that occurred within 30 days after discharge]). There was a negative association between surgical volume and the incidence of surgical site infection following coronary artery bypass graft surgery. The hospital volume has a greater effect than does surgeon volume on reducing the incidence of surgical site infection.     

Measuring spatial effects in time to event data: a case study using months from angiography to coronary artery bypass graft (CABG)

The application of Bayesian hierarchical models to measure spatial effects in time to event data has not been widely reported. This case study aims to estimate the effect of area of residence on waiting times to coronary artery bypass graft (CABG) and to assess the role of important individual specific covariates (age, sex and disease severity). The data involved all patients with definite coronary artery disease who were referred to one cardiothoracic unit from five contiguous health authorities covering 488 electoral wards (areas). Time to event was the waiting time in months from angiography (diagnosis) to CABG (event). A number of discrete time survival models were fitted to the data. A discrete baseline hazard was estimated by fitting waiting time non-parametrically into the models. Ward was fitted as a spatial effect using a Gaussian Markov random field prior. Individual specific covariates considered were age, sex and number of diseased vessels. The recently proposed DIC criteria was used for comparing models. Results showed a marked spatial effect on time to bypass surgery after including age, sex and disease severity in the model. Notably this spatial effect was not apparent when these covariates were not included in the model. The observed small area spatial variation in time to CABG warrants further investigation.     

Surgery volume, quality of care and operative mortality in coronary artery bypass graft surgery: a re-examination using fixed-effects regression

For many surgical procedures, apparent volume–outcome relationships may reflect differences in patient risk-profiles as well as quality of care. As some important patient profile differences may be unobserved, we use fixed effects (FE) regression to estimate the relationship between operative mortality and surgeon and hospital volumes, and compare this method with the more commonly used random effects (RE) regression approach. The 1998 and 1999 Medicare Inpatient and Denominator files for Medicare Fee for Service enrollees aged 65–99. Operative mortality rates are estimated for different surgeon and hospital volume tertiles (high, medium, low) using FE and RE regression methods, adjusted for patient demographics and morbidities. The data were collected by the Centers for Medicare and Medicaid Services (CMS). FE regression estimates that lowest volume tertile hospitals have 1.4 and lowest volume tertile surgeons have 1.6 additional operative deaths (for every 100 CABG surgeries) compared to their highest volume tertile counterparts. The corresponding RE estimates are 0.5 and 1.4 respectively. The substantially higher FE hospital volume effect compared to RE indicates the presence of unobserved “protective” characteristics in lower volume providers, including a less complicated patient profile. Lower hospital and surgeon volumes are associated with substantially higher excess operative mortality from CABG surgeries than previously estimated.     

Cost-effectiveness analysis of coronary arteries bypass grafting (CABG) and percutaneous coronary intervention (PCI) through drug stent in iran: a comparative study

Emerging evidence suggests that structured and progressive exercise underpinned by a cognitive behavioural approach can improve functional outcomes in patients with neurogenic claudication (NC). However, evidence surrounding its economic benefits is lacking. To estimate the economic costs, health-related quality of life outcomes and cost-effectiveness of a physical and psychological group intervention (BOOST programme) versus best practice advice (BPA) in older adults with NC. An economic evaluation was conducted based on data from a pragmatic, multicentre, superiority, randomised controlled trial. The base-case economic evaluation took the form of an intention-to-treat analysis conducted from a UK National Health Service (NHS) and personal social services (PSS) perspective and separately from a societal perspective. Costs (£ 2018–2019 prices) were collected prospectively over a 12 month follow-up period. A bivariate regression of costs and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted to estimate the incremental cost per QALY gained and the incremental net monetary benefit (INMB) of the BOOST programme in comparison to BPA. Sensitivity and pre-specified subgroup analyses explored uncertainty and heterogeneity in cost-effectiveness estimates. Participants (N?=?435) were randomised to the BOOST programme (n?=?292) or BPA (n?=?143). Mean (standard error [SE]) NHS and PSS costs over 12 months were £1,974 (£118) in the BOOST arm versus £1,827 (£169) in the BPA arm (p?=?0.474). Mean (SE) QALY estimates were 0.620 (0.009) versus 0.599 (0.006), respectively (p?=?0.093). The probability that the BOOST programme is cost-effective ranged between 67 and 83% (NHS and PSS perspective) and 79–89% (societal perspective) at cost-effectiveness thresholds between £15,000 and £30,000 per QALY gained. INMBs ranged between £145 and £464 at similar cost-effectiveness thresholds. The cost-effectiveness results remained robust to sensitivity analyses. The BOOST programme resulted in modest QALY gains over the 12 month follow-up period. Future studies with longer intervention and follow-up periods are needed to address uncertainty around the health-related quality of life impacts and cost-effectiveness of such programmes. Trial registration This study has been registered in the International Standard Randomised Controlled Trial Number registry, reference number ISRCTN12698674. Registered on 10 November 2015.     

Psychological status and the role of coping style after coronary artery bypass graft surgery. Results of a prospective study

The results of a prospective study in patients who underwent a first coronary artery bypass graft operation are presented. The goals of this project consisted in assessing the psychological changes during the first year after surgery. For that purpose, 330 consecutive patients were recruited. They were assessed by means of several psychological scales before and on three occasions after surgery. These scales were: the Heart Patients' Psychological Questionnaire (HPPQ), the State–Trait Anxiety Scale (STAI), the Symptom Check List (SCL-90), the Maastricht Questionnaire (MQ) and the Marlowe Crowne Desirability Scale. Furthermore, the study focused on the differential influence of three coping styles. The data demonstrate a clear overall improvement in psychological status over the first year, more specifically during the first 6 months after CABG. Patients were less anxious, less depressed, less exhausted and experienced more subjective well-being. However, almost 30% of all patients did not experience that average favourable evolution. The final psychological end-state was predicted by psychological variables, measured pre-operatively (somatic complaints, hostility and dysphoria) and short-term post-operatively (anxiety). No single medical variable could predict patients' psychological end-state. Finally, the most favourable change was made by patients who display the sensitising coping style, resulting in lower anxiety and depression. Health care providers, physicians as well as nursing staff and psychologists, should therefore use psychodiagnostic tools in order to identify patients at risk for negative psychological outcome. Appropriate therapeutic interventions may consequently be developed and evaluated in future research.     

Increase in the rate of sternal surgical site infection after coronary artery bypass graft: a marker of higher severity of illness.

OBJECTIVE: To evaluate factors related to a gradual rise in sternal surgical site infection (SSI) rates. DESIGN: Retrospective cohort study. SETTING: A 608-bed, tertiary care teaching hospital. PATIENTS: All patients who underwent coronary artery bypass graft (CABG) from January 2000 through September 2004. RESULTS: Of 3,578 patients who underwent CABG, 144 (4%) had sternal SSI. There was an increase in infection rate, with a marked reduction in the number of operations per year. The percentage of patients with peripheral vascular disease increased from 12% to 24.3% (P<.001), and the percentage with congestive heart failure increased from 17% to 22% (P<.001). Between 2002 and 2004, the mean duration of surgery increased from 233 to 290 minutes (P<.001), the percentage of patients with a National Nosocomial Infections Surveillance System (NNIS) risk index of 2 increased from 14.3% to 38% (P<.001), and the percentage of patients with a postoperative stay in the intensive care unit of greater than 72 hours increased from 29% to 40.6% (P<.001). Multivariate analysis showed diabetes mellitus, peripheral vascular disease, obesity, duration of surgery, and postoperative stay in the intensive care unit of greater than 72 hours to be independently associated with infection. CONCLUSIONS: An increase in infection in the CABG population not associated with an outbreak may be a reflection of a change in the severity of illness. Preoperative, intraoperative, and postoperative markers for increased infection risk may be used, in addition to the NNIS risk index, to assess the patient population risk.     

Assessing equity in access to health care provision in the UK: does where you live affect your chances of getting a coronary artery bypass graft?

STUDY OBJECTIVES--Equity should be monitored routinely for all health care services, but ideal studies for each service would be prohibitively expensive and time consuming. A simple, quick, and cheap method for the preliminary exploration of equity in health care provision using routine data was devised. This method was illustrated by examining whether coronary artery bypass graft (CABG) operations reflect socioeconomic differences in ischaemic heart disease (IHD) mortality. DESIGN--Ecological comparison of operation rates was undertaken for CABG for 1991 and IHD mortality for 1981-85 by quartiles of Townsend deprivation score. SETTING--North East Thames Regional Health Authority, London, UK. SUBJECTS--All residents of this region aged 35-74 were the denominator population. Numerators were 26,834 IHD deaths and 1041 CABG operations for the defined time periods. MAIN RESULTS--IHD mortality showed a steady, significant increase with increasing area deprivation scores for both men and women. CABG rate ratios increased linearly for women, while for men there was a U shaped pattern, being lowest for the second and third quartiles. This pattern was attenuated, but not abolished, when adjusted for geographical proximity to cardiothoracic surgical units. The ratio of CABG operations to IHD mortality by deprivation was relatively constant in women suggesting equitable provision. In men, this ratio was significantly lower for the third quartile. CONCLUSIONS--Inequities may exist in the provision of CABG operations for men in this region and this finding should be the stimulus for further detailed studies. Other health care systems should also examine equity in provision.     

Blacks in the coronary artery surgery study (CASS): race and clinical decision making.

For patients enrolled in the Coronary Artery Surgery Study (CASS), surgery was recommended for 46.5 per cent of Blacks and 59.4 per cent of Whites, despite similar clinical and angiographic characteristics. Of those recommended, 80.5 per cent of Blacks and 90.4 per cent of Whites had bypass surgery. These differences were most apparent for Black laborers. Overall, only 38.0 per cent of Blacks had coronary artery bypass surgery, whereas 58.4 per cent of Whites received surgery.     

Data on secondary prevention of coronary artery disease in Hungary and some changes in the last ten years (EUROASPIRE 1995-2005)

In year 1995 the European Society of Cardiology started an epidemiological study EUROASPIRE to evaluate the results of secondary prevention in some European countries. The first study period was in 1995, the second in 1999-2000 and the third in 2007. From Hungary the same study centers participated in EUROASPIRE I-II-III investigation. Authors present the Hungarian data and changes occurring the last ten years. During the three studies, 1627 coronary patients- younger than 70 years - were evaluated, using standardized methods. In the two Hungarian study centers, the proportion of women and patients older than 60 years increased. The hospital documentation of risk factors improved, at the time of EUROASPIRE III necessary data were found in 89%-99% of patient's records. Mean systolic and diastolic blood pressure continuously decreased between the first and second study period, but at the time of the third study 44% of the patients had elevated blood pressure (>140/90 mmHg). Prevalence of smoking decreased by 8% between second and third study period, however, at the time of the last study, 18% of coronary patients were smokers. The mean of total cholesterol was lower in the last study period comparing to the first investigation (5.6 vs. 5.2 mmol/l). HDL cholesterol level was unchanged and increasing triglyceride values were observed. During the study period the prevalence of obesity continuously increased from 23% to 49%. Prevalence of patients with total cholesterol level 5.5 mmol/l or higher has decreased from 60% to 24%, however 57% of patients did not reach the target level (4.5 mmol/l) although 80% of patients were treated with lipid lowering drugs: 76% of them received statins. Authors say that some part of secondary prevention improved during the last ten years, but many patients did not reach the target blood pressure and cholesterol level and it is embarrassing the prevalence of obesity and diabetes. The published data are not representative for whole Hungary; most probably the general situation is worse. Authors emphasize the importance of secondary prevention in the graduate and postgraduate education. For improving the secondary prevention, better cooperation is needed between hospital staff and patients and general practitioners as well.     

Associations between neighborhood characteristics and self-rated health: A cross-sectional investigation in the Multi-Ethnic Study of Atherosclerosis (MESA) cohort

Quantifying the effects of specific neighborhood features on self-reported health is important in understanding the global health impact of neighborhood context. We investigated associations of neighborhood poverty, sociability and walkability with self-rated physical and mental health in the Multi-Ethnic Study of Atherosclerosis (MESA). In separate models, each neighborhood variable was associated with physical health but associations with sociability and walkability were stronger than those for poverty. Only walkability remained significant after adjusting for the other neighborhood variables. There was no evidence that self-rated mental health as assessed by the SF12 was associated with neighborhood poverty, walkability or sociability. This study provides information on how neighborhood context is associated with global health in diverse midlife and older persons.     

复方丹参制剂与曲美他嗪对冠脉搭桥术后合并心衰患者BNP及CRP的影响

目的探讨复方丹参制剂与曲美他嗪对冠脉搭桥术后合并心衰患者BNP(脑纳尿肽)及CRP(c反应蛋白)的影响。方法分析某院自2008年1月～2011年1月收治的冠脉搭桥术后出现心衰的患者104例,其中56例给予复方丹参制剂与曲美他嗪,其他48例给予常规处理,比较两组患者BNP及CRP水平的变化。结果应用复方丹参制剂与曲美他嗪的观察组比对照组BNP、CRP水平均显著降低(P=0.036,P=0.016)。观察组BNP、CRP水平在心功能Ⅱ级、Ⅲ级、Ⅳ级,均显著低于对照组(P=0.014,P=0.045,P=0.036;P=0.041,P=0.042,P=0.039)。结论复方丹参制剂与曲美他嗪可以有效地降低冠脉搭桥术后合并心衰患者BNP及CRP,保护心脏功能,促进搭桥术后的心脏功能恢复。     

Subjective health complaints, health-related quality of life and physician visits: results of the study of health in Pomerania (SHIP)

Summary. Objectives To investigate the relationship between subjective health complaints (SHCs), health-related quality of life and physician visits. Method 3’773 participants of the Study of Health in Pomerania (SHIP) filled questionnaires and were interviewed. Data consisted of 1) 38 statements concerning SHCs, 2) the SF12, and 3) statements concerning visits to 11 different groups of physicians. Factor analysis was done on the SHC data, with a subsequent varimax rotation. Relationships between resulting factors and remaining variables were analysed using 1) the cumulative logit model for the first SF12 item (overall health evaluation), 2) linear regression for the physical and mental sum scores of the SF12, and 3) logistic regression for physician visits. Results Eight factors have eigenvalues greater than one and together explain 54.2% of total variance. Varimax rotated factors can be interpreted easily. Altogether, these factors, sex and age significantly affect the first SF12 item (Nagelkerke’s R² = 0.27), both sum scores (physical: R²adj. = 0.40; mental: R²adj. = 0.36), and all physician visits (Nagelkerke’s R² between 0.03 and 0.23). Conclusions Subjective health complaints are important. Total sum scores of typical SHC questionnaires do not reflect all relevant aspects of SHCs. Submitted: 17 December 2003 Accepted: 3 March 2006     

Effect of apolipoprotein E polymorphism on the serum lipid and insulin response to whole grain consumption in coronary artery disease patients

Whether apo E polymorphism influenced serum lipids and insulin response to the isocalorical replacement of refined rice with whole grains was investigated in coronary artery disease (CAD) men with a low-fat diet. CAD men (n=110) were switched from their basal diet (61% carbohydrate and 19% fat) to isoenergetic diet containing 70g whole grain powder (220kcal), as a carbohydrate source of breakfast for 16 weeks. Apo E2 group (n=11) showed higher baseline serum triglyceride than apo E3 group (n=82). Baseline serum concentrations of total and LDL cholesterol and apo B were highest in apo E4 group (n=16), intermediate in apo E3 and lowest in apo E2. Apo E3 groups showed significantly decreases of triglyceride, total and LDL cholesterol and apo B by 12%, 5%, 8% and 8% after 16 weeks, respectively. In apo E4 group, similar decrease of LDL cholesterol and apo B was observed. HDL cholesterol significantly increased by 8% and 15% in apo E3 and E4 groups, respectively. Apo E3 group showed about 9% decrease in fasting insulin and glucose. Apo E genotype modified the serum lipids and insulin response to the isocalorical replacement of refined rice with whole grains in CAD men with a low-fat diet; apo E2 subjects were non-responders, while apo E3 subjects were favorable responders.     

Co-variation between biological markers and self-reported alcohol consumption. A two-year study of the relationship between changes in consumption and changes in the biological markers gamma-glutamyl transpeptidase (GGT) and average volume per erythrocyte (MCV) among problem drinkers.

Co-variations between self-reported alcohol consumption and the biological markers MCV (average volume per erythrocyte) and GGT (gamma-glutamyl transpeptidase) over a 2-year period were studied in a group of 84 men and 53 women recruited to out-patient treatment by advertisements in the press. Upon admission, the drinking pattern of the participants during the preceding year was registered in detail. The participants were also medically examined, and blood samples taken. All the participants were followed up by new personal interviews, medical examinations and new blood sampling after 3, 9, 25 and 21 months. For the group as a whole, alcohol consumption was significantly lower at the end of the observation period than at admission. GGT was also decreased, but not MCV. Both self-reported consumption and the values for the biological markers showed large inter-individual and intra-individual variations during the observation period. The biological markers seemed to co-vary to a limited degree with changes in reported consumption. Both GGT and MCV seemed to have a low sensitivity but a high specificity to changes in consumption. Both markers also seemed to be somewhat more useful in identifying decreases than increases in consumption. The markers GGT and MCV should be used with caution in connection with therapeutic counselling to individuals.     

Use of the multispecies freshwater biomonitor to assess behavioral changes of Corophium volutator (Pallas, 1766) (Crustacea, Amphipoda) in response to toxicant exposure in sediment

Automated sediment toxicity testing and biomonitoring has grown rapidly. This study tested the suitability of the marine amphipod Corophium volutator (Pallas, 1766) for sediment biomonitoring using the Multispecies Freshwater Biomonitor (MFB). Two experiments were undertaken to (1) characterize individual behaviors of C. volutator using the MFB and (2) examine behavioral changes in response to sediment spiked with the pesticide Bioban. Four behaviors were visually identified (walking, swimming, grooming and falling) and characterized in the MFB as different patterns of locomotor activity (0-2 Hz range). Ventilation was not visually observed but was detected by the MFB (2-8 Hz). No clear diel activity patterns were detected. The MFB detected an overall increase in C. volutator locomotor activity after Bioban addition to the sediments (56, 100, 121 mg kg(-1)). C. volutator was more active (both locomotion and ventilation) in the water column than the spiked sediment. C. volutator appears a sensitive and appropriate species for behavioral sediment toxicity assessment and biomonitoring.     

Sexual cleansing (Kusalazya) and levirate marriage (Kunjilila mung'anda) in the era of AIDS: changes in perceptions and practices in Zambia.

Since sexual cleansing (kusalazya) and the intertwined ritual of levirate marriage or widow and widower inheritance (kunjilila mung'anda) have come to be implicated in the transmission of HIV/AIDS, alternative rituals to sexual cleansing have emerged. Using both quantitative and qualitative data obtained from Zambia in the second half of 1998, this study reveals that the alternative rituals to sexual cleansing include sliding over a half-naked person (kucuta) or over an animal (kucuta ng'ombe or cow-jumping); use of herbs and roots (misamu); cleansing by a married couple. Concoctions or other rituals that were otherwise considered 'alien' in Southern Province, such as cutting of hair (kugela masusu) and application of some powder (kunanika busu), have also been adopted. The study, therefore, discusses various aspects of these alternative practices: who performs them and how; whether the processes are connected to polygyny (maali), levirate marriage (kunjilila mung'anda), and grabbing or inheriting property (kukona); and whether these practices are also risk factors in the spread of HIV/AIDS.