Surgical aortic valve replacement in the era of transcatheter aortic valve implantation: a review of the UK national database

Objectives To date the reported outcomes of surgical aortic valve replacement (SAVR) are mainly in the settings of trials comparing it with evolving transcatheter aortic valve implantation. We set out to examine characteristics and outcomes in people who underwent SAVR reflecting a national cohort and therefore ‘real-world’ practice. Design Retrospective analysis of prospectively collected data of consecutive people who underwent SAVR with or without coronary artery bypass graft (CABG) surgery between April 2013 and March 2018 in the UK. This included elective, urgent and emergency operations. Participants’ demographics, preoperative risk factors, operative data, in-hospital mortality, postoperative complications and effect of the addition of CABG to SAVR were analysed. Setting 27 (90%) tertiary cardiac surgical centres in the UK submitted their data for analysis. Participants 31 277 people with AVR were identified. 19 670 (62.9%) had only SAVR and 11 607 (37.1%) had AVR+CABG. Results In-hospital mortality for isolated SAVR was 1.9% (95% CI 1.6% to 2.1%) and was 2.4% for AVR+CABG. Mortality by age category for SAVR only were: 75 years=2.2%. For SAVR+CABG these were; 2.2%, 1.8% and 3.1%. For different categories of EuroSCORE, mortality for SAVR in low risk people was 1.3%, in intermediate risk 1% and for high risk 3.9%. 74.3% of the operations were elective, 24% urgent and 1.7% emergency/salvage. The incidences of resternotomy for bleeding and stroke were 3.9% and 1.1%, respectively. Multivariable analyses provided no evidence that concomitant CABG influenced outcome. However, urgency of the operation, poor ventricular function, higher EuroSCORE and longer cross clamp and cardiopulmonary bypass times adversely affected outcomes. Conclusions Surgical SAVR±CABG has low mortality risk and a low level of complications in the UK in people of all ages and risk factors. These results should inform consideration of treatment options in people with aortic valve disease

The Nile: its role in the fortunes and misfortunes of the Fatimid dynasty during its rule of Egypt (969-1171)

The epoch spanning the years 935-1094 constitutes - on the whole - the longest and driest period on record in the history of the Nile. A stretch of relatively normal discharge followed this phase, only for dryness to return. The reasons of this dry-wet-dry phenomenon have been recently appraised in the context of global climatic changes – the so-called “Medieval Warm Period” - that affected most of the known world between the 11th and the 13th centuries. It was in this period of Egyptian history that the Shi‘i Isma‘ili Fatimids replaced the Sunni Ikhshidids as rulers in 358/969 and, with alternating fortunes, continued to reign until 567/1171. In this paper, I examine how, faced with the convergence of extraordinary geo-climatic factors, the Fatimids managed (and mismanaged) the Nile and its valley. I contend that the imperial aspirations of the Fatimids in Cairo and beyond were in many ways subject to the typical unpredictability of the natural cycles of the river, hence the Fatimids’ success and failure in managing the varied economic, political and trading activities that took place along the Egyptian section of the Nile valley. A case in point highlighted here will be the Fatimids’ privileging of flax cultivation over wheat

Surgical aortic valve replacement in the era of transcatheter aortic valve implantation: a review of the UK national database.

OBJECTIVES: To date the reported outcomes of surgical aortic valve replacement (SAVR) are mainly in the settings of trials comparing it with evolving transcatheter aortic valve implantation. We set out to examine characteristics and outcomes in people who underwent SAVR reflecting a national cohort and therefore 'real-world' practice. DESIGN: Retrospective analysis of prospectively collected data of consecutive people who underwent SAVR with or without coronary artery bypass graft (CABG) surgery between April 2013 and March 2018 in the UK. This included elective, urgent and emergency operations. Participants' demographics, preoperative risk factors, operative data, in-hospital mortality, postoperative complications and effect of the addition of CABG to SAVR were analysed. SETTING: 27 (90%) tertiary cardiac surgical centres in the UK submitted their data for analysis. PARTICIPANTS: 31 277 people with AVR were identified. 19 670 (62.9%) had only SAVR and 11 607 (37.1%) had AVR+CABG. RESULTS: In-hospital mortality for isolated SAVR was 1.9% (95% CI 1.6% to 2.1%) and was 2.4% for AVR+CABG. Mortality by age category for SAVR only were: 75 years=2.2%. For SAVR+CABG these were; 2.2%, 1.8% and 3.1%. For different categories of EuroSCORE, mortality for SAVR in low risk people was 1.3%, in intermediate risk 1% and for high risk 3.9%. 74.3% of the operations were elective, 24% urgent and 1.7% emergency/salvage. The incidences of resternotomy for bleeding and stroke were 3.9% and 1.1%, respectively. Multivariable analyses provided no evidence that concomitant CABG influenced outcome. However, urgency of the operation, poor ventricular function, higher EuroSCORE and longer cross clamp and cardiopulmonary bypass times adversely affected outcomes. CONCLUSIONS: Surgical SAVR±CABG has low mortality risk and a low level of complications in the UK in people of all ages and risk factors. These results should inform consideration of treatment options in people with aortic valve disease

Stability of democracies:A complex systems perspective

The idea that democracy is under threat, after being largely dormant for at least 40 years, is looming increasingly large in public discourse. Complex systems theory offers a range of powerful new tools to analyse the stability of social institutions in general, and democracy in particular. What makes a democracy stable? And which processes potentially lead to instability of a democratic system? This paper offers a complex systems perspective on this question, informed by areas of the mathematical, natural, and social sciences. We explain the meaning of the term ‘stability’ in different disciplines and discuss how laws, rules, and regulations, but also norms, conventions, and expectations are decisive for the stability of a social institution such as democracy

High value manufacturing : capability, appropriation, and governance

Manufacturing competitiveness is on many policy agendas, born out of a concern for firms in high-cost economies finding themselves outcompeted by low-cost rivals. Government policy makers and manufacturing firm strategists have put their faith in what we label as high value manufacturing (HVM). We see HVM as an incipient phenomenon currently in a situation of prescience, as something that is still “in-the-making,” with manufacturing firms trying to find ways to be able to step away from having to compete on price. This paper consults relevant strategy theories with the purpose to pinpoint the issues and problems that need to be accommodated for bringing HVM into being and for creating the effects that are anticipated. We found that HVM must be seen as a distributed activity, thus realizing complex functionality for a system-of-use, while being subjected to path constitution. For HVM to function, the firms involved need to find solutions to the capability problem, the appropriation problem, and the governance problem. We suggest that further research needs to involve itself in problem-solving activity to assist in bringing HVM about while simultaneously further developing strategy theory geared toward firms that are involved in a distributed activity like HVM