Assessing the Long-term Patency and Clinical Outcomes of Venous and Arterial Grafts Used in Coronary Artery Bypass Grafting: A Meta-analysis

Introduction The long-term patency of the grafts used during the coronary artery bypass grafting (CABG) is one of the most significant predictors of the clinical outcomes. The gold standard graft used during CABG with the best long-term patency rate and the better clinical outcomes is left internal thoracic artery (LITA) grafted to the left coronary artery (LCA). The controversy lies in choosing the second-best conduit for the non-left coronary artery (NLCA) with similar patency rate as LITA. This meta-analysis examines the long-term patency and clinical outcomes of all arterial grafts versus all venous grafts used during the CABG. Methods A comprehensive literature search of all published randomized control trials (RCTs) assessing long-term patency and clinical outcomes of grafts used in CABG was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2018). Keywords searched included combinations of CABG , venous grafts in CABG , arterial grafts in CABG , radial artery grafts in CABG , gastroepiploic artery grafts in CABG , patency and clinical outcomes . Inclusion criteria included: RCTs comparing the long-term patency, and clinical outcomes of radial artery, right internal thoracic artery, gastroduodenal artery, and saphenous vein grafts used in CABG. Long-term patency of the grafts and clinical outcomes were analyzed. Results Eight RCTs involving 2,091 patients with 1,164 patients receiving arterial grafts and 927 patients receiving venous grafts were included. There was no difference between the long-term patency rate (relative risk (RR) = 1.050, 95% confidence interval (CI) = 0.949 to 1.162, and p = 0.344), overall mortality rate (RR = 1.095, 95% CI = 0.561 to 2.136, and p = 0.790), rate of myocardial infarction (MI) (RR = 0.860, 95% CI = 0.409 to 1.812, and P = 0.692), and re-intervention rate (RR = 0.0768, 95% CI = 0.419 to 1.406, and P = 0.392) between arterial and venous grafts. Conclusion The use of arterial conduits over the venous conduits has no significant superiority regarding the long-term graft patency, the rate of MI, overall mortality, and the rate of revascularization following CABG. Additional adequately powered studies are needed to further evaluate the long-term outcomes of arterial and venous grafts following the CABG

Steroid treatment in ARDS: a critical appraisal of the ARDS network trial and the recent literature

Objective: To compare the design and results of randomized trials investigating prolonged glucocorticoid treatment (>= 7 days) in patients with acute lung injury-acute respiratory distress syndrome (ALI-ARDS), and review factors affecting response to therapy, including the role of secondary prevention. Design: Trials were retrieved from the Cochrane Central Register of Controlled Trials (CENTRAL). Two investigators collected data on study characteristics, treatment intervention, and outcomes. The methodological quality of trials was determined and data were analyzed with Review Manager 4.2.3. Measurements and results: Five selected trials (n = 518) consistently reported significant improvement in gas exchange, reduction in markers of inflammation, and decreased duration of mechanical ventilation and intensive care unit stay (all p < 0.05). Two early small clinical trials showed marked reductions in the relative risk (RR) of death with glucocorticoid therapy (RR = 0.14, 95% CI 0.04-0.53; p = 0.004, I-2 = 0%). Three subsequent larger trials, when combined, although nominally beneficial, did not reproduce the marked reductions observed in the earlier trials (RR = 0.84; 95% CI 0.68-1.03; p = 0.09, I-2 = 9.1%), but achieved a distinct reduction in the RR of death in the larger subgroup of patients (n = 400) treated before day 14 of ARDS [82/214 (38%) vs. 98/186 (52.5%), RR = 0.78; 95% CI 0.64-0.96; p = 0.02, I-2 = 0%]. Conclusions: Prolonged glucocorticoid treatment substantially and significantly improves meaningful patient-centered outcome variables, and has a distinct survival benefit when initiated before day 14 of ARDS

C L I N I C A L C O MME N T A R Y Steroid treatment in ARDS: a critical appraisal of the ARDS network trial and the recent literature

Abstract Objectives: To compare the design and results of randomized trials investigating prolonged glucocorticoid treatment (≥ 7 days) in patients with acute lung injury-acute respiratory distress syndrome (ALI-ARDS), and review factors affecting response to therapy, including the role of secondary prevention. Design: Trials were retrieved from the Cochrane Central Register of Controlled Trials (CENTRAL). Two investigators collected data on study characteristics, treatment intervention, and outcomes. The methodological quality of trials was determined and data were analyzed with Review Manager 4.2.3. Measurements and results: Five selected trials (n = 518) consistently reported significant improvement in gas exchange, reduction in markers of inflammation, and decreased duration of mechanical ventilation and intensive care unit stay (all p < 0.05). Two early small clinical trials showed marked reductions in the relative risk (RR) of death with glucocorticoid therapy (RR = 0.14, 95% CI 0.04-0.53; p = 0.004, I 2 = 0%). Three subsequent larger trials, when combined, although nominally beneficial, did not reproduce the marked reductions observed in the earlier trials (RR = 0.84; 95% CI 0.68-1.03; p = 0.09, I 2 = 9.1%), but achieved a distinct reduction in the RR of death in the larger subgroup of patients (n = 400) treated before day 14 of ARDS [82/214 (38%) vs. 98/186 (52.5%), RR = 0.78; 95% CI 0.64-0.96; p = 0.02, I 2 = 0%]. Conclusions: Prolonged glucocorticoid treatment substantially and significantly improves meaningful patient-centered outcome variables, and has a distinct survival benefit when initiated before day 14 of ARDS

Intensive Care Med (2008) 34:61–69 DOI 10.1007/s00134-007-0933-3 CLINICAL COMMENTARY

Steroid treatment in ARDS: a critical appraisal of the ARDS network trial and the recent literatur

Practice management guidelines for the screening of thoracolumbar spine fracture.

BACKGROUND: Fractures to the thoracolumbar spine (TLS) commonly occur because of major trauma mechanisms. In one series, 4.4% of all patients arriving at a Level I trauma center were diagnosed as having TLS fracture. Approximately 19% to 50% of these fractures in the TLS region will be associated with neurologic damage to the spinal cord. To date there are no randomized studies and only a few prospective studies specifically addressing the subject. The Eastern Association for the Surgery of Trauma organization Practice Management Guidelines committee set out to develop an EBM guideline for the diagnosis of TLS fractures. METHODS: A computerized search of the National Library of Medicine and the National Institutes of Health MEDLINE database was undertaken using the PubMed Entrez (www.pubmed.gov) interface. The primary search strategy was developed to retrieve English language articles focusing on diagnostic examination of potential TLS injury published between 1995 and March 2005. Articles were screened based on the following questions. (1) Does a patient who is awake, nonintoxicated, without distracting injuries require radiographic workup or a clinical examination only? (2) Does a patient with a distracting injury, altered mental status, or pain require radiographic examination? (3) Does the obtunded patient require radiographic examination? RESULTS: Sixty-nine articles were identified after the initial screening process, all of which dealt with blunt injury to the TLS, along with clinical, radiographic, fluoroscopic, and magnetic resonance imaging evaluation. From this group, 32 articles were selected. The reviewers identified 27 articles that dealt with the initial evaluation of TLS injury after trauma. CONCLUSION: Computed tomography (CT) scan imaging of the bony spine has advanced with helical and currently multidetector images to allow reformatted axial collimation of images into two-dimensional and three-dimensional images. As a result, bony injuries to the TLS are commonly being identified. Most blunt trauma patients require CT to screen for other injuries. This has allowed the single admitting series of CT scans to also include screening for bony spine injuries. However, all of the publications fail to clearly define the criteria used to decide who gets radiographs or CT scans. No study has carefully conducted long-term follow-up on all of their trauma patients to identify all cases of TLS injury missed in the acute setting