The effect of completeness of revascularization during CABG with single versus multiple arterial grafts

IntroductionIncomplete coronary revascularization is associated with suboptimal outcomes. We investigated the longâ term effects of Incomplete, Complete, and Supraâ complete revascularization and whether these effects differed in the setting of singleâ arterial and multiâ arterial coronary artery bypass graft (CABG).MethodsWe analyzed 15â year mortality in 7157 CABG patients (64.1â ±â 10.5 years; 30% women). All patients received a left internal thoracic artery to left anterior descending coronary artery graft with additional venous grafts only (singleâ arterial) or with at least one additional arterial graft (multiâ arterial) and were grouped based on a completeness of revascularization index (CRIâ =â number of grafts minus the number of diseased principal coronary arteries): Incomplete (CRIâ â ¤â â 1 [Nâ =â 320;4.5%]); Complete (CRIâ =â 0 [Nâ =â 2882;40.3%]; reference group); and two Supraâ complete categories (CRIâ =â +1[Nâ =â 3050; 42.6%]; CRIâ â ¥â +â 2 [Nâ =â 905; 12.6%]). Riskâ adjusted mortality hazard ratios (AHR) were calculated using comprehensive propensity score adjustment by Cox regression.ResultsIncomplete revascularization was rare (4.5%) but associated with increased mortality in all patients (AHR [95% confidence interval]â =â 1.53 [1.29â 1.80]), those undergoing singleâ arterial CABG (AHRâ =â 1.27 [1.04â 1.54]) and multiâ arterial CABG (AHRâ =â 2.18 [1.60â 2.99]), as well as in patients with 3â Vessel (AHRâ =â 1.37 [1.16â 1.62]) and, to a lesser degree, with 2â Vessel (AHRâ =â 1.67 [0.53â 5.23]) coronary disease. Supraâ complete revascularization was generally associated with incrementally decreased mortality in all patients (AHR [CRIâ =â +1]â =â 0.94 [0.87â 1.03]); AHR [CRIâ â ¥â +2]â =â 0.74 [0.64â 0.85]), and was driven by a significantly decreased mortality risk in singleâ arterial CABG (AHR [CRIâ =â +1]â =â 0.90 [0.81â 0.99]; AHR [CRIâ â ¥â +2]â =â 0.64 [0.53â 0.78]); and 3â Vessel disease patients (AHR [CRIâ =â +1]â =â 0.94 [0.86â 1.04]; and AHR [CRIâ â ¥â +2]â =â 0.75 [0.63â 0.88]) with no impact in multiâ arterial CABG (AHR [CRIâ =â +1]â =â 1.07 [0.91â 1.26]; AHR [CRIâ â ¥â +2]â =â 0.93 [0.73â 1.17]).ConclusionsIncomplete revascularization is associated with decreased late survival, irrespective of grafting strategy. Alternatively, supraâ complete revascularization is associated with improved survival in patients with 3â Vessel CAD, and in singleâ arterial but not multiâ arterial CABG.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146364/1/jocs13810.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/146364/2/jocs13810_am.pd

A systematic review of clinical decision support systems for antimicrobial management: are we failing to investigate these interventions appropriately?

Objectives Clinical decision support systems (CDSS) for antimicrobial management can support clinicians to optimize antimicrobial therapy. We reviewed all original literature (qualitative and quantitative) to understand the current scope of CDSS for antimicrobial management and analyse existing methods used to evaluate and report such systems. Method PRISMA guidelines were followed. Medline, EMBASE, HMIC Health and Management and Global Health databases were searched from 1 January 1980 to 31 October 2015. All primary research studies describing CDSS for antimicrobial management in adults in primary or secondary care were included. For qualitative studies, thematic synthesis was performed. Quality was assessed using Integrated quality Criteria for the Review Of Multiple Study designs (ICROMS) criteria. CDSS reporting was assessed against a reporting framework for behaviour change intervention implementation. Results Fifty-eight original articles were included describing 38 independent CDSS. The majority of systems target antimicrobial prescribing (29/38;76%), are platforms integrated with electronic medical records (28/38;74%), and have a rules-based infrastructure providing decision support (29/38;76%). On evaluation against the intervention reporting framework, CDSS studies fail to report consideration of the non-expert, end-user workflow. They have narrow focus, such as antimicrobial selection, and use proxy outcome measures. Engagement with CDSS by clinicians was poor. Conclusion Greater consideration of the factors that drive non-expert decision making must be considered when designing CDSS interventions. Future work must aim to expand CDSS beyond simply selecting appropriate antimicrobials with clear and systematic reporting frameworks for CDSS interventions developed to address current gaps identified in the reporting of evidence

Cardiac rehabilitation in Austria: long term health-related quality of life outcomes

<p>Abstract</p> <p>Background</p> <p>The goal of cardiac rehabilitation programs is not only to prolong life but also to improve physical functioning, symptoms, well-being, and health-related quality of life (HRQL). The aim of this study was to document the long-term effect of a 1-month inpatient cardiac rehabilitation intervention on HRQL in Austria.</p> <p>Methods</p> <p>Patients (N = 487, 64.7% male, age 60.9 ± 12.5 SD years) after myocardial infarction, with or without percutaneous interventions, coronary artery bypass grafting or valve surgery underwent inpatient cardiac rehabilitation and were included in this long-term observational study (two years follow-up). HRQL was measured with both the MacNew Heart Disease Quality of Life Instrument [MacNew] and EuroQoL-5D [EQ-5D].</p> <p>Results</p> <p>All MacNew scale scores improved significantly (p < 0.001) and exceeded the minimal important difference (0.5 MacNew points) by the end of rehabilitation. Although all MacNew scale scores deteriorated significantly over the two year follow-up period (p < .001), all MacNew scale scores still remained significantly higher than the pre-rehabilitation values. The mean improvement after two years in the MacNew social scale exceeded the minimal important difference while MacNew scale scores greater than the minimal important difference were reported by 40-49% of the patients.</p> <p>Two years after rehabilitation the mean improvement in the EQ-5D Visual Analogue Scale score was not significant with no significant change in the proportion of patients reporting problems at this time.</p> <p>Conclusion</p> <p>These findings provide a first indication that two years following inpatient cardiac rehabilitation in Austria, the long-term improvements in HRQL are statistically significant and clinically relevant for almost 50% of the patients. Future controlled randomized trials comparing different cardiac rehabilitation programs are needed.</p

Phylogenetic Analysis of a Spontaneous Cocoa Bean Fermentation Metagenome Reveals New Insights into Its Bacterial and Fungal Community Diversity

This is the first report on the phylogenetic analysis of the community diversity of a single spontaneous cocoa bean box fermentation sample through a metagenomic approach involving 454 pyrosequencing. Several sequence-based and composition-based taxonomic profiling tools were used and evaluated to avoid software-dependent results and their outcome was validated by comparison with previously obtained culture-dependent and culture-independent data. Overall, this approach revealed a wider bacterial (mainly γ-Proteobacteria) and fungal diversity than previously found. Further, the use of a combination of different classification methods, in a software-independent way, helped to understand the actual composition of the microbial ecosystem under study. In addition, bacteriophage-related sequences were found. The bacterial diversity depended partially on the methods used, as composition-based methods predicted a wider diversity than sequence-based methods, and as classification methods based solely on phylogenetic marker genes predicted a more restricted diversity compared with methods that took all reads into account. The metagenomic sequencing analysis identified Hanseniaspora uvarum, Hanseniaspora opuntiae, Saccharomyces cerevisiae, Lactobacillus fermentum, and Acetobacter pasteurianus as the prevailing species. Also, the presence of occasional members of the cocoa bean fermentation process was revealed (such as Erwinia tasmaniensis, Lactobacillus brevis, Lactobacillus casei, Lactobacillus rhamnosus, Lactococcus lactis, Leuconostoc mesenteroides, and Oenococcus oeni). Furthermore, the sequence reads associated with viral communities were of a restricted diversity, dominated by Myoviridae and Siphoviridae, and reflecting Lactobacillus as the dominant host. To conclude, an accurate overview of all members of a cocoa bean fermentation process sample was revealed, indicating the superiority of metagenomic sequencing over previously used techniques