Postoperative atrial fibrillation in patients on statins undergoing isolated cardiac valve surgery: a meta-analysis

Introduction: The efficacy of perioperative statin therapy in decreasing postoperative morbidity in patients undergoing valve replacements and repairs is unknown. The aim of our study was to determine whether or not the literature supports the hypothesis that statins decrease postoperative atrial fibrillation (AF), and hence improve short-term postoperative outcomes in patients undergoing isolated cardiac valve surgery.Method: We conducted a meta-analysis of studies on postoperative outcomes associated with statin therapy following isolated valve replacement or repair. The data was taken from published studies on valvular heart surgery patients. Participants were patients who underwent either isolated cardiac valve replacement or repair. Patients in the intervention group received statins prior to their surgery. Three databases were searched: Ovid Healthstar, 1966 to April 2012; Ovid Medline, 1946 to 31 May 2012; and Embase, 1974 to 30 May 2012. The meta-analysis was conducted using Review Manager® version 5.1.Results: Statins did not decrease the incidence of postoperative AF in patients undergoing isolated cardiac valve surgery [odds ratio (OR) 1.19, 95% confidence interval (CI): 0.80– 1.77)], although there was significant heterogeneity for the outcome of postoperative AF (I2 55%, 95% CI: 27–72). Statins were associated with a decrease in 30-day mortality (OR 0.43, 95% CI: 0.24–0.75).Conclusion: Although this meta-analysis suggests that chronic statin therapy did not prevent postoperative AF in unselected valvular heart surgical patients, the heterogeneity indicates that this outcome should be viewed with caution and further research is recommended.Keywords: atrial fibrillation, cardiac surgery, statin

Preoperative B-type natriuretic peptides in patients undergoing noncardiac surgery: a cumulative meta-analysis

Background: A plethora of studies have shown elevated preoperative natriuretic peptide measurements to predict postoperative mortality and adverse cardiac events.Objectives: The current study aimed to demonstrate this overwhelming association and to show that further studies of this nature are unwarranted.Methods: A cumulative meta-analysis of 28 studies was conducted where the primary outcomes of  mortality and adverse cardiac events were associated with elevated preoperative natriuretic peptides.Results: Cumulative meta-analysis demonstrated an odds ratio trending to a constant of 5.66, with a marked narrowing in the 95% confidence interval.Conclusions: Further studies aiming only to demonstrate an association between a preoperative natriuretic peptide threshold and the risk of postoperative adverse cardiac events are not justified. Future investigation should focus on the clinical implications of these data and the application of these findings with regard to further investigation, optimisation and appropriate adaptation of perioperative management.Keywords: BNP, major adverse cardiac event, myocardial injury, natriuretic peptides, non-cardiac surgery, NT-proBNP, outcome

A critical analysis of Discovery Health’s claims-based risk adjustment of mortality rates in South African private sector hospitals

In 2019, Discovery Health published a risk adjustment model to determine standardised mortality rates across South African private hospital systems, with the aim of contributing towards quality improvement in the private healthcare sector. However, the model suffers from limitations due to its design and its reliance on administrative data. The publication’s aim of facilitating transparency is unfortunately undermined by shortcomings in reporting. When designing a risk prediction model, patient-proximate variables with a sound theoretical or proven association with the outcome of interest should be used. The addition of key condition-specific clinical data points at the time of hospital admission will dramatically improve model performance. Performance could be further improved by using summary risk prediction scores such as the EUROSCORE II for coronary artery bypass graft surgery or the GRACE risk score for acute coronary syndrome. In general, model reporting should conform to published reporting standards, and attempts should be made to test model validity by using sensitivity analyses. In particular, the limitations of machine learning prediction models should be understood, and these models should be appropriately developed, evaluated and reported.http://www.samj.org.zaam2023Gordon Institute of Business Science (GIBS

A meta-analysis of the efficacy of preoperative surgical safety checklists to improve perioperative outcomes

Background. Meta-analyses of the implementation of a surgical safety checklist (SSC) in observational studies have shown a significant decrease in mortality and surgical complications.Objective. To determine the efficacy of the SSC using data from randomised controlled trials (RCTs).Methods. This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with PROSPERO (CRD42015017546). A comprehensive search of six databases was conducted using the OvidSP search engine.Results. Four hundred and sixty-four citations revealed three eligible trials conducted in tertiary hospitals and a community hospital, with a total of 6 060 patients. All trials had allocation concealment bias and a lack of blinding of participants and personnel. A single trial that contributed 5 295 of the 6 060 patients to the meta-analysis had no detection, attrition or reporting biases. The SSC was associated with significantly decreased mortality (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.42 - 0.85; p=0.0004; I2=0%) and surgical complications (RR 0.64, 95% CI 0.57 - 0.71; p<0.00001; I2=0%). The efficacy of the SSC on specific surgical complications was as follows: respiratory complications RR 0.59, 95% CI 0.21 - 1.70; p=0.33, cardiac complications RR 0.74, 95% CI 0.28 - 1.95; p=0.54, infectious complications RR 0.61, 95% CI 0.29 - 1.27; p=0.18, and perioperative bleeding RR 0.36, 95% CI 0.23 - 0.56; p<0.00001.Conclusions. There is sufficient RCT evidence to suggest that SSCs decrease hospital mortality and surgical outcomes in tertiary and community hospitals. However, randomised evidence of the efficacy of the SSC at rural hospital level is absent

Enhancing legacy in palliative care: study protocol for a randomized controlled trial of Dignity Therapy focused on positive outcomes

BACKGROUND: Dignity Therapy is a brief psychotherapy that can enhance a sense of legacy while addressing the emotional and existential needs of patients receiving hospice or palliative care. In Dignity Therapy, patients create a formalized “legacy” document that records their most cherished memories, their lessons learned in life, as well as their hopes and dreams for loved ones in the future. To date, this treatment has been studied for its impact on mitigating distress within hospice and palliative care populations and has provided mixed results. This study will instead focus on whether Dignity Therapy enhances positive outcomes in this population. METHODS/DESIGN: In this study, 90 patients with cancer receiving hospice or palliative care will complete a mixed-methods randomized controlled trial of Dignity Therapy (n = 45) versus Supportive Attention (n = 45). The patients will be enrolled in the study for 3 weeks, receiving a total of six study visits. The primary outcomes examine whether the treatment will quantitatively increase levels of positive affect and a sense of life closure. Secondary outcomes focus on gratitude, hope, life satisfaction, meaning in life, resilience, and self-efficacy. Using a fixed, embedded dataset design, this study will additionally use qualitative interviews to explore patients’ perceptions regarding the use of positive outcome measures and whether these outcomes are appropriately matched to their experiences in therapy. DISCUSSION: Dignity Therapy has shown mixed results when evaluating its impact on distress, although no other study to date has solely focused on the potential positive aspects of this treatment. This study is novel in its use of mixed methods assessments to focus on positive outcomes, and will provide valuable information about patients’ direct experiences in this area. TRIAL REGISTRATION: ISRCTN9138919

Evolutionary History of Hunter-Gatherer Marriage Practices

Background: The universality of marriage in human societies around the world suggests a deep evolutionary history of institutionalized pair-bonding that stems back at least to early modern humans. However, marriage practices vary considerably from culture to culture, ranging from strict prescriptions and arranged marriages in some societies to mostly unregulated courtship in others, presence to absence of brideservice and brideprice, and polyandrous to polygynous unions. The ancestral state of early human marriage is not well known given the lack of conclusive archaeological evidence. Methodology: Comparative phylogenetic analyses using data from contemporary hunter-gatherers around the world may allow for the reconstruction of ancestral human cultural traits. We attempt to reconstruct ancestral marriage practices using hunter-gatherer phylogenies based on mitochondrial DNA sequences. Results: Arranged marriages are inferred to go back at least to first modern human migrations out of Africa. Reconstructions are equivocal on whether or not earlier human marriages were arranged because several African hunter-gatherers have courtship marriages. Phylogenetic reconstructions suggest that marriages in early ancestral human societies probably had low levels of polygyny (low reproductive skew) and reciprocal exchanges between the families of marital partners (i.e., brideservice or brideprice). Discussion: Phylogenetic results suggest a deep history of regulated exchange of mates and resources among lineages tha