Does off-pump coronary revascularization confer superior organ protection in re-operative coronary artery surgery? A meta-analysis of observational studies

Off-pump coronary artery bypass surgery (OPCAB) has been hypothesised to be beneficial in the high-risk patient population undergoing re-operative coronary artery bypass graft surgery (CABG). In addition, this technique has been demonstrated to provide subtle benefits in end-organ function including heart, lungs and kidney. The aims of this study were to assess whether OPCAB is associated with a lower incidence of major adverse cardiovascular and cerebrovascular events (MACCE) and other adverse outcomes in re-operative coronary surgery. Twelve studies, incorporating 3471 patients were identified by systematic literature review. These were meta-analysed using random-effects modelling. Primary endpoints were MACCE and other adverse outcomes including myocardial infarction, stroke, renal dysfunction, low cardiac output state, respiratory failure and atrial fibrillation. A significantly lower incidence of myocardial infarction, stroke, renal dysfunction, low cardiac output state, respiratory failure and atrial fibrillation was observed with OPCAB (OR 0.58; 95% CI (confidence interval) [0.39-0.87]; OR 0.37; 95% CI [0.17-0.79]; OR 0.39; 95% CI [0.24-0.63]; OR 0.14; 95% CI [0.04-0.56]; OR 0.36; 95% CI [0.24-0.54]; OR 0.41; 95% CI [0.22-0.77] respectively). Sub-group analysis using sample size, matching score and quality score was consistent with and reflected these significant findings. Off-pump coronary artery bypass grafting reduces peri-operative and short-term major adverse outcomes in patients undergoing re-operative surgery. Consequently we conclude that OPCAB provides superior organ protection and a safer outcome profile in re-operative CABG

A Systematic Review of Investigations into Functional Brain Connectivity Following Spinal Cord Injury

Background: Complete or incomplete spinal cord injury (SCI) results in varying degree of motor, sensory and autonomic impairment. Long-lasting, often irreversible disability results from disconnection of efferent and afferent pathways. How does this disconnection affect brain function is not so clear. Changes in brain organization and structure have been associated with SCI and have been extensively studied and reviewed. Yet, our knowledge regarding brain connectivity changes following SCI is overall lacking. Methods: In this study we conduct a systematic review of articles regarding investigations of functional brain networks following SCI, searching on PubMed, Scopus and ScienceDirect according to PRISMA-P 2015 statement standards. Results: Changes in brain connectivity have been shown even during the early stages of the chronic condition and correlate with the degree of neurological impairment. Connectivity changes appear as dynamic post-injury procedures. Sensorimotor networks of patients and healthy individuals share similar patterns but new functional interactions have been identified as unique to SCI networks. Conclusions: Large-scale, multi-modal, longitudinal studies on SCI patients are needed to understand how brain network reorganization is established and progresses through the course of the condition. The expected insight holds clinical relevance in preventing maladaptive plasticity after SCI through individualized neurorehabilitation, as well as the design of connectivity-based brain-computer interfaces and assistive technologies for SCI patients

Trends in immediate postmastectomy breast reconstruction in the United Kingdom

The study aimed to evaluate local and national trends in immediate breast reconstruction (IBR) using the national English administrative records, Hospital Episode Statistics. Our prediction was an increase in implant-only and free flap procedures and a decline in latissimus flap reconstructions.Data from an oncoplastic center were interrogated to derive numbers of implant-only, autologous latissimus dorsi (LD), LD-assisted, and autologous pedicled or free flap IBR procedures performed between 2004 and 2013. Similarly, Hospital Episode Statistics data were used to quantify national trends in these procedures from 1996 to 2012 using a curve fitting analysis.National data suggest an increase in LD procedures between 1996 (n = 250) and 2002 (n = 958), a gradual rise until 2008 (n = 1398) followed by a decline until 2012 (n = 1090). As a percentage of total IBR, trends in LD flap reconstruction better fit a quadratic (R(2) = 0.97) than a linear function (R(2) = 0.63), confirming a proportional recent decline in LD flap procedures. Conversely, autologous (non-LD) flap reconstructions have increased (1996 = 0.44%; 2012 = 2.76%), whereas implant-only reconstructions have declined (1996 = 95.42%; 2012 = 84.92%). Locally, 70 implant-assisted LD procedures were performed in 2003 -2004, but only 2 were performed in 2012 to 2013.Implants are the most common IBR technique; autologous free flap procedures have increased, and pedicled LD flap procedures are in decline

Influence of Body Mass Index on outcomes after minimal-access aortic valve replacement through a J-shaped partial upper sternotomy

BACKGROUND: Minimal-access aortic valve replacement (MAAVR) may reduce post-operative blood loss and transfusion requirements, decrease post-operative pain, shorten length stay and enhance cosmesis. This may be particularly advantageous in overweight/obese patients, who are at increased risk of post-operative complications. Obese patients are however often denied MAAVR due to the perceived technical procedural difficulty. This retrospective analysis sought to determine the effect of BMI on post-operative outcomes in patients undergoing MAAVR. METHODS: Ninety isolated elective MAAVR procedures performed between May 2006–October 2013 were included. Intra- and post-operative data were prospectively collected. Ordinary least squares univariate linear regression analysis was performed to determine the effect of BMI as a continuous variable on post-operative outcomes. One-way ANOVA and Chi-squared testing was used to assess differences in outcomes between patients with BMI <25 (n = 36) and BMI ≥25 (n = 54) as appropriate. RESULTS: There was no peri-operative mortality, myocardial infarction or stroke. Univariate regression demonstrated longer cross-clamp times (p = 0.0218) and a trend towards increased bypass times (p = 0.0615) in patients with higher BMI. BMI ≥25 was associated with an increased incidence of hospital-acquired pneumonia (p = 0.020) and new-onset atrial fibrillation (p = 0.036) compared to BMI <25. However, raised BMI did not extend ICU (p = 0.3310) or overall hospital stay (p = 0.2614). Similar rates of sternal wound complications, inotrope requirements and renal dysfunction were observed in both normal- and overweight/obese-BMI groups. Furthermore, increasing BMI correlated with reduced mechanical ventilation time (p = 0.039) and early post-operative blood loss (p = 0.004). CONCLUSIONS: Our results demonstrate that within the range of this study, MAAVR is a safe, reproducible and effective procedure, affording equivalent clinical outcomes in both overweight/obese and normal-weight patients considered for an isolated first-time AVR, with low post-operative morbidity and mortality. MAAVR should therefore be considered as an alternative surgical strategy to reduce obesity-related complications in patients requiring aortic valve replacement

The role of minimal access valve surgery in the elderly. A meta-analysis of observational studies

Background Minimal access valve surgery, both mitral and aortic, may be related to improvement in specific post-operative outcomes, therefore may be beneficial for the subgroup of the elderly referred for valve surgery. Methods A systematic literature review identified several different studies, of which 6 fulfilled criteria for meta-analysis. Outcomes for a total of 1347 patients (675 conventional standard sternotomy and 672 minimally invasive valve surgery) were assessed with a meta-analysis using random effects modeling. Heterogeneity, subgroup analysis with quality scoring were also assessed. The primary endpoint was early mortality. Secondary endpoints included intra and post-operative outcomes. Results In the context of elderly patients, minimal access valve surgery conferred comparable early mortality to standard sternotomy (odd ratio (OR) 0.79, CI [0.40,1.56], p\ua0=\ua00.50) with no heterogeneity (p\ua0=\ua00.13); it was also associated with reduced mechanical intubation time (OR 0.48, CI [0.30,0.78], p\ua0=\ua00.003) and reduced post-operative length of stay (weighted mean difference (WMD)\ua0 122.91, CI [ 123.09,\ua0 122.74] p\ua0<\ua00.00001), however both cardio-pulmonary bypass time and cross clamp time were longer (WMD 24.29, CI [22.97, 25.61] p\ua0<\ua00.00001 and WMD 8.61, CI [7.61, 9.61], p\ua0<\ua00.00001, respectively); subgroup analysis demonstrated statistically significant reduced post-operative length of stay for both minimally invasive aortic and mitral surgery (WMD\ua0 122.84, CI [ 123.07,\ua0 122.60] p\ua0<\ua00.00001 and WMD\ua0 122.98, CI [ 123.25,\ua0 122.71] p\ua0<\ua00.00001 respectively). Conclusions Despite a prolonged cardiopulmonary bypass and cross clamp time, minimally invasive valve surgery is a safe alternative to standard sternotomy in the elderly, with similar early mortality, and improvements in intubation time as well as length of stay

Temporally and spatially resolved photoluminescence investigation of (11(2)over-bar2) semi-polar InGaN/GaN multiple quantum wells grown on nanorod templates

By means of time-resolved photoluminescence (PL) and confocal PL measurements, temporally and spatially resolved optical properties have been investigated on a number of InxGa1−xN/GaN multiple-quantum-well (MQW) structures with a wide range of indium content alloys from 13% to 35% on (112⎯⎯2)(112¯2) semi-polar GaN with high crystal quality, obtained through overgrowth on nanorod templates. With increasing indium content, the radiative recombination lifetime initially increases as expected, but decreases if the indium content further increases to 35%, corresponding to emission in the green spectral region. The reduced radiative recombination lifetime leads to enhanced optical performance for the high indium content MQWs as a result of strong exciton localization, which is different from the behaviour of c-plane InGaN/GaN MQWs, where quantum confined Stark effect plays a dominating role in emission process

The value of real world evidence: the case of medical cannabis

Randomised controlled trials (RCTs) have long been considered the gold standard of medical evidence. In relation to cannabis based medicinal products (CBMPs), this focus on RCTs has led to very restrictive guidelines in the UK, which are limiting patient access. There is general agreement that RCT evidence in relation to CBPMs is insufficient at present. As well as commercial reasons, a major problem is that RCTs do not lend themselves well to the study of whole plant medicines. One solution to this challenge is the use of real world evidence (RWE) with patient reported outcomes (PROs) to widen the evidence base. Such data increasingly highlights the positive impact medical cannabis can have on patients’ lives. This paper outlines the value of this approach which involves the study of interventions and patients longitudinally under medical care. In relation to CBMPs, RWE has a broad range of advantages. These include the study of larger groups of patients, the use of a broader range and ratio of components of CBMPs, and the inclusion of more and rarer medical conditions. Importantly, and in contrast to RCTs, patients with significant comorbidities–and from a wider demographic profile–can also be studied, so providing higher ecological validity and increasing patient numbers, whilst offering significant cost savings. We conclude by outlining 12 key recommendations of the value of RWE in relation to medical cannabis. We hope that this paper will help policymakers and prescribers understand the importance of RWE in relation to medical cannabis and help them develop approaches to overcome the current situation which is detrimental to patients

Polymeric endovascular strut and lumen detection algorithm for intracoronary optical coherence tomography images

Polymeric endovascular implants are the next step in minimally invasive vascular interventions. As an alternative to traditional metallic drug-eluting stents, these often-erodible scaffolds present opportunities and challenges for patients and clinicians. Theoretically, as they resorb and are absorbed over time, they obviate the long-term complications of permanent implants, but in the short-term visualization and therefore positioning is problematic. Polymeric scaffolds can only be fully imaged using optical coherence tomography (OCT) imaging—they are relatively invisible via angiography—and segmentation of polymeric struts in OCT images is performed manually, a laborious and intractable procedure for large datasets. Traditional lumen detection methods using implant struts as boundary limits fail in images with polymeric implants. Therefore, it is necessary to develop an automated method to detect polymeric struts and luminal borders in OCT images; we present such a fully automated algorithm. Accuracy was validated using expert annotations on 1140 OCT images with a positive predictive value of 0.93 for strut detection and an R^2 correlation coefficient of 0.94 between detected and expert-annotated lumen areas. The proposed algorithm allows for rapid, accurate, and automated detection of polymeric struts and the luminal border in OCT images