Endoscopic Vein Harvesting for Coronary Bypass Grafting: A Blessing or a Trojan Horse?

Conventional open harvest of the great saphenous vein (GSV) during CABG results in approximately 7% donor-site complications. Using endoscopic vein harvesting (EVH) the full GSV length can be harvested through a 3 cm incision. This nonsystematic review discusses several key issues concerning EVH, based on an extensive Pubmed search. Found studies show that EVH results in reduced number of wound complications, less postoperative pain, earlier postoperative mobilisation, reduced length of hospital stay, and is more cost-effective. Initial studies did not find significant differences in graft histology, patency, or clinical outcome. However, in 2009 convincing evidence of inferior histological graft properties became available. Furthermore, an observational study showed that EVH resulted in significantly more graft stenosis, was associated with higher mortality, more myocard infarction, and more reinterventions. Most recent publications could not confirm these findings, however larger randomised controlled trials focusing on graft quality are being awaited

ON THE USE OF FIBER REINFORCED POLYMER COMPOSITE ELEMENTS FOR ENHANCING STRUCTURAL STEEL MEMBER DUCTILITY

An innovative use of fiber reinforced polymer (FRP) composite materials, to control the manifestation of local buckling in a steel section during plastic hinging is discussed in the present work. Specifically, details related to how the high stiffness and linear behavior of FRP materials may be utilized to provide "bracing" against flange local buckling (FLB), in a way that strategically leverages the unique mechanical properties of each material in an efficient application domain, are discussed. The proposed method is not aimed at increasing the load carrying capacity of the steel section, per se; although this may certainly be accomplished if desired. Rather, the present paper reports on a novel technique that is aimed at providing stability (in the sense of bracing) to the steel section through the imposition FRP strips whose function is to enforce a nodal line along a plate element for the purposes of: increasing its critical load; and constraining plastic flow in the plate element. The member becomes, in affect, an FRP stabilized steel section. The research work discussed herein is primarily analytical in nature. Detailed nonlinear finite element models are created using the commercially available software system ADINA

Breast cancer survivorship:long-term physical and psychological effects of breast cancer and its treatment

Breast cancer is the most common cancer among women in the Netherlands. Fortunately, due to better screening and treatments, survival has improved. The purpose of this study was to assess whether breast cancer survivors, five or more years after diagnosis, experience physical or psychological effects of breast cancer and its treatment. For that, we performed the BLOC (Breast cancer Long-term Outcome of Cardiac function) study, in primary care. We included an unselected population of 350 breast cancer survivors, at least five years after breast cancer diagnosis. These women were matched to 350 women of the same age and general practitioner, who had no history of (breast) cancer.The results show that breast cancer survivors (an average of ten years after diagnosis) are more likely to have mild cardiac dysfunction and cardiovascular disease than women of the same age and general practitioner without a history of cancer. Also, breast cancer survivors more often experience (severe) symptoms of depression, anxiety, and fatigue. It is important to raise awareness of these long-term effects of breast cancer and its treatment, as they may have an impact on the quality of life of these women. We also need to improve information to (future) survivors about these long-term effects. We believe that the results of this study can also be used to improve future guidelines for general practitioners, who, on average, have 21 breast cancer survivors in their practice. Fortunately, most breast cancer survivors will not experience long-term effects; however, we must recognize those who do

Effects of Combination Lipid Therapy in Type 2 Diabetes Mellitus

BACKGROUND—We investigated whether combination therapy with a statin plus a fibrate, as compared with statin monotherapy, would reduce the risk of cardiovascular disease in patients with type 2 diabetes mellitus who were at high risk for cardiovascular disease. METHODS—We randomly assigned 5518 patients with type 2 diabetes who were being treated with open-label simvastatin to receive either masked fenofibrate or placebo. The primary outcome was the first occurrence of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes. The mean follow-up was 4.7 years. RESULTS—The annual rate of the primary outcome was 2.2% in the fenofibrate group and 2.4% in the placebo group (hazard ratio in the fenofibrate group, 0.92; 95% confidence interval [CI], 0.79 to 1.08; P = 0.32). There were also no significant differences between the two study groups with respect to any secondary outcome. Annual rates of death were 1.5% in the fenofibrate group and 1.6% in the placebo group (hazard ratio, 0.91; 95% CI, 0.75 to 1.10; P = 0.33). Prespecified subgroup analyses suggested heterogeneity in treatment effect according to sex, with a benefit for men and possible harm for women (P = 0.01 for interaction), and a possible interaction according to lipid subgroup, with a possible benefit for patients with both a high baseline triglyceride level and a low baseline level of high-density lipoprotein cholesterol (P = 0.057 for interaction). CONCLUSIONS—The combination of fenofibrate and simvastatin did not reduce the rate of fatal cardiovascular events, nonfatal myocardial infarction, or nonfatal stroke, as compared with simvastatin alone. These results do not support the routine use of combination therapy with fenofibrate and simvastatin to reduce cardiovascular risk in the majority of high-risk patients with type 2 diabetes. (ClinicalTrials.gov number, NCT00000620.

Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus

BACKGROUND—There is no evidence from randomized trials to support a strategy of lowering systolic blood pressure below 135 to 140 mm Hg in persons with type 2 diabetes mellitus. We investigated whether therapy targeting normal systolic pressure (i.e., <120 mm Hg) reduces major cardiovascular events in participants with type 2 diabetes at high risk for cardiovascular events. METHODS—A total of 4733 participants with type 2 diabetes were randomly assigned to intensive therapy, targeting a systolic pressure of less than 120 mm Hg, or standard therapy, targeting a systolic pressure of less than 140 mm Hg. The primary composite outcome was nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes. The mean follow-up was 4.7 years. RESULTS—After 1 year, the mean systolic blood pressure was 119.3 mm Hg in the intensivetherapy group and 133.5 mm Hg in the standard-therapy group. The annual rate of the primary outcome was 1.87% in the intensive-therapy group and 2.09% in the standard-therapy group (hazard ratio with intensive therapy, 0.88; 95% confidence interval [CI], 0.73 to 1.06; P = 0.20). The annual rates of death from any cause were 1.28% and 1.19% in the two groups, respectively (hazard ratio, 1.07; 95% CI, 0.85 to 1.35; P = 0.55). The annual rates of stroke, a prespecified secondary outcome, were 0.32% and 0.53% in the two groups, respectively (hazard ratio, 0.59; 95% CI, 0.39 to 0.89; P = 0.01). Serious adverse events attributed to antihypertensive treatment occurred in 77 of the 2362 participants in the intensive-therapy group (3.3%) and 30 of the 2371 participants in the standard-therapy group (1.3%) (P <0.001). CONCLUSIONS—In patients with type 2 diabetes at high risk for cardiovascular events, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, did not reduce the rate of a composite outcome of fatal and nonfatal major cardiovascular events. (ClinicalTrials.gov number, NCT00000620.

Long-Term Effects of Intensive Glucose Lowering on Cardiovascular Outcomes

BACKGROUND—Intensive glucose lowering has previously been shown to increase mortality among persons with advanced type 2 diabetes and a high risk of cardiovascular disease. This report describes the 5-year outcomes of a mean of 3.7 years of intensive glucose lowering on mortality and key cardiovascular events. METHODS—We randomly assigned participants with type 2 diabetes and cardiovascular disease or additional cardiovascular risk factors to receive intensive therapy (targeting a glycated hemoglobin level below 6.0%) or standard therapy (targeting a level of 7 to 7.9%). After termination of the intensive therapy, due to higher mortality in the intensive-therapy group, the target glycated hemoglobin level was 7 to 7.9% for all participants, who were followed until the planned end of the trial. RESULTS—Before the intensive therapy was terminated, the intensive-therapy group did not differ significantly from the standard-therapy group in the rate of the primary outcome (a composite of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes) (P = 0.13) but had more deaths from any cause (primarily cardiovascular) (hazard ratio, 1.21; 95% confidence interval [CI], 1.02 to 1.44) and fewer nonfatal myocardial infarctions (hazard ratio, 0.79; 95% CI, 0.66 to 0.95). These trends persisted during the entire follow-up period (hazard ratio for death, 1.19; 95% CI, 1.03 to 1.38; and hazard ratio for nonfatal myocardial infarction, 0.82; 95% CI, 0.70 to 0.96). After the intensive intervention was terminated, the median glycated hemoglobin level in the intensive-therapy group rose from 6.4% to 7.2%, and the use of glucoselowering medications and rates of severe hypoglycemia and other adverse events were similar in the two groups. CONCLUSIONS—As compared with standard therapy, the use of intensive therapy for 3.7 years to target a glycated hemoglobin level below 6% reduced 5-year nonfatal myocardial infarctions but increased 5-year mortality. Such a strategy cannot be recommended for high-risk patients with advanced type 2 diabetes. (Funded by the National Heart, Lung and Blood Institute; ClinicalTrials.gov number, NCT00000620.

Long-term psychological distress in breast cancer survivors and their matched controls:A cross-sectional study

Introduction: Breast cancer survivors often experience psychological distress shortly after diagnosis. Long-term psychological effects, however, have not been clearly demonstrated. Methods: This cross-sectional cohort study included 350 breast cancer survivors and 350 age-matched and general-practitioner-matched women. The median follow-up was 10 years. Using logistic regression we compared breast cancer survivors with controls on having (severe) symptoms of depression and/or anxiety, as measured with the Hospital Anxiety and Depression Scale. In multivariable logistic regression, we adjusted the results for a history of depression or prescription of antidepressants. Results: Larger proportions of breast cancer survivors experienced symptoms of depression (10.6%) compared with controls (4.9%) and symptoms of anxiety (18.6%) compared with controls (16.3%). The odds of symptoms of depression (OR 2.3, 95%CI 1.3-4.2), severe symptoms of depression (OR 3.3, 95%CI 1.1-10.3) and severe symptoms of anxiety (OR 2.1, 95%CI, 1.1-4.0) were significantly higher for breast cancer survivors than for controls, even after adjusting for history of depression or prescription of antidepressants. No significant difference was seen for mild symptoms of anxiety. Conclusions: Breast cancer survivors have an increased risk of symptoms of depression, including severe symptoms, and severe symptoms of anxiety compared with controls, for up to at least 10 years after diagnosis

Epidemiology of Micro- and Macrovascular Complications of Type 2 Diabetes in Korea

The prevalence of diabetes in Korea has increased six- to sevenfold over the past 40 years with its complications becoming major causes of morbidity and mortality. The rate of death among patients with diabetes is about twice as high as that among persons without diabetes and the most common cause of death is cardiovascular disease (30.6%). Despite the seriousness of diabetic complications, 30 to 70% of patients receive inadequate care, and only 40% of treated diabetic patients achieve the optimal control with HbA1c level <7% in Korea. In 2006, over 30 to 40% of patients with diabetes have microvascular complications and around 10% of them have macrovascular complications from our national data. Despite there are some debates about intensive glycemic control resulting in the deterioration of macrovascular complication, multifactorial treatment approaches including proper glycemic control are important to prevent diabetic complications. There have been needs for finding proper biomarkers for predicting diabetic complications properly but we still need more longitudinal studies to find this correlation with causal relationship. In this article, we wanted to review the recent status of micro- and macrovascular complications of type 2 diabetes in Korea from integration of many epidemiologic studies