Atrial fibrillation after minimally invasive direct coronary artery bypass surgery

AbstractOBJECTIVESThe study compared the adjusted risk for developing atrial fibrillation (AF) after minimally invasive direct coronary artery bypass surgery (MIDCAB) and coronary artery bypass graft surgery (CABG).BACKGROUNDAtrial fibrillation results in increased morbidity and delays hospital discharge after CABG. Recently, MIDCAB has been explored as an alternative to CABG. Because of differences in surgical approach between the two procedures, the incidence of AF may differ.METHODSRandomly selected patients undergoing CABG and MIDCAB were examined. Baseline variables and postoperative course were recorded through review of medical record data.RESULTSThe MIDCAB patients were younger than CABG patients (64 ± 12 vs. 67 ± 10, p < 0.04) and had less extensive coronary artery disease (53% of MIDCAB vs. 3% of CABG had single-vessel disease, while 15% of MIDCAB vs. 69% of CABG had triple-vessel disease, p < 0.001 for overall group comparisons). No other differences in clinical or treatment data were noted. Postoperative AF occurred less often after MIDCAB (23% vs 39%, p = 0.02). Other significant factors associated with postoperative AF included age (p = 0.0024), prior AF (p = 0.0007), left main disease (p = 0.01), number of vessels bypassed (p = 0.009), absence of postoperative beta-blocker therapy (p = 0.0001), and a serious postoperative complication (p = 0.0018). Because of differences between CABG and MIDCAB patients, multivariate logistic analysis was performed to determine independent predictors of postoperative AF. The type of surgery (CABG vs. MIDCAB) was no longer a significant predictor of postoperative AF (estimated relative risk for AF in CABG vs. MIDCAB patients: 1.57, 95% confidence interval (0.82–2.52).CONCLUSIONSAlthough AF appears to be less common after MIDCAB than after CABG, the lower incidence is due to different clinical characteristics of patients undergoing these procedures

Cumulative effects assessment: proof of concept marine mammals

This development of the framework and approach for a Cumulative Effects Assessment (CEA) is based on a literature review. The literature identified some key challenges that need to be addressed for CEA to evolve into a consistent, appropriate tool to assist decision-making. These challenges included • A clear distinction of the receptor-led CEA from the dominating stressor-led Environmental Impact Assessment (EIA) approaches and • Enabling CEA to provide ecosystem-relevant information at an appropriate regional scale. Therefore this CEA is explicitly developed to be a receptor-led and fully integrated framework, i.e. involving multiple occurrences of multiple pressures (from single and/or different sources) on multiple receptors, as opposed to other existing approaches dealing with only a subset of those pressures or receptors, hence our use of the phrase iCEA for integrated CEA. As a proof of concept for this iCEA we selected one receptor, the ecosystem component marine mammals. The main conclusions of this exercise (see Chapter 6) are that the iCEA framework and approach presented in this study appear suitable to fulfil its main purpose and ultimately inform the policy process as described in the conception phase. However it should be acknowledged this is only the very first step in a process where through many iterations new information can be introduced and assessed (relative to existing information) based on the criteria provided resulting in an improved iCEA with increasing confidence levels. As more information becomes available the relative importance of impact chains and its corresponding information modules may change giving direction to new areas for research. For further development of this iCEA towards its intended applications we can distinguish between the first purpose, i.e. identification of the main impact chains contributing to the risk that a specific ecosystem component is impacted, which can be achieved with the approach presented here focussing on one specific ecosystem component and the second purpose, i.e. an evaluation of the performance of possible management strategies, which would require all ecosystem components to be included as would be required for ecosystem-based management. Thus to further the development and application of this iCEA towards its (two) purpose(s) the recommendation is to: • Include the available information presented in this report into the iCEA and develop the Bayesian Belief Network such that it can process this information and its associated confidence into an assessment that identifies the main impact chains for the marine mammals. • Extend the framework and approach to (all) the other ecosystem components so that a truly integrated CEA is possible. Note that this is likely to affect the identification of what should be considered the main pressures to guide management. • Improve the information modules that emerged from the evaluation as the most promising to increase the confidence in the outcome of the iCEA. Note that the previous two steps may result in a different prioritisation of the information modules as the importance of pressures and hence impact chains changes

Impact of Regional Systems of Care on Disparities in Care Among Female and Black Patients Presenting With ST‐Segment–Elevation Myocardial Infarction

BACKGROUND: The American Heart Association Mission: Lifeline STEMI (ST-segment-elevation myocardial infarction) Systems Accelerator program, conducted in 16 regions across the United States to improve key care processes, resulted in more patients being treated within national guideline goals (time from first medical contact to device: <90 minutes for direct presenters to hospitals capable of performing percutaneous coronary intervention; <120 minutes for transfers). We examined whether the effort reduced reperfusion disparities in the proportions of female versus male and black versus white patients. METHODS AND RESULTS: In total, 23 809 patients (29.3% female, 82.3% white, and 10.7% black) presented with acute STEMI between July 2012 and March 2014. Change in the proportion of patients treated within guideline goals was compared between sex and race subgroups for patients presenting directly to hospitals capable of performing percutaneous coronary intervention (n=18 267) and patients requiring transfer (n=5542). The intervention was associated with an increase in the proportion of men treated within guideline goals that presented directly (58.7-62.1%, P=0.01) or were transferred (43.3-50.7%, P<0.01). An increase was also seen among white patients who presented directly (57.7-59.9%, P=0.02) or were transferred (43.9-48.8%, P<0.01). There was no change in the proportion of female or black patients treated within guideline goals, including both those presenting directly and transferred. CONCLUSION: The STEMI Systems Accelerator project was associated with an increase in the proportion of patients meeting guideline reperfusion targets for male and white patients but not for female or black patients. Efforts to organize systems of STEMI care should implement additional processes targeting barriers to timely reperfusion among female and black patients

Quickscan impact van visserij en opties voor begrenzing van een oesterbank in de Voordelta

Platte oesters (Ostrea edulis) vormen riffen met een grote biodiversiteit. In 2015 werd in de Voordelta bij de Brouwerdam een wilde bank (ca 40 ha) ontdekt, bestaande uit platte oesters en andere schelpdieren en begroeid met diverse andere soorten. Onder OSPAR en de Habitatrichtlijn kwalificeren oesterbanken als te beschermen habitat, maar op dit moment is het rif in de Voordelta nog niet beschermd. Om de oesterbank beter in beeld te brengen -in aanloop naar mogelijke verdere bescherming- wordt het als onderzoeksgebied aangemerkt (2021-2024), waarvoor visserijmaatregelen zullen worden ingesteld. Daarbij zullen de leeftijdsopbouw, overleving en reproductie van platte oesters in kaart worden gebracht evenals de geassocieerde biodiversiteit. De eerste kennisvraag is welke visserijvormen mogelijk schade zouden kunnen veroorzaken aan benthos/hardsubstraatbewonende organismen, inclusief oesters. Deze vraag is beantwoord met behulp van literatuuronderzoek, aangevuld met expert judgement en een gesprek met de enige visser die in het gebied actief is. Hierbij is uitgegaan van het voorzorgprincipe. De tweede vraag is welke begrenzing rondom het rif gehanteerd zou kunnen worden als visserijmaatregel. Bodemberoerende visserijvormen, zoals garnalenvisserij, zullen het rif zeker aantasten. Voor passieve visserijvormen zoals kooien, korven en staand want, zijn de fysieke effecten op benthos/hardsubstraatbewonende organismen, waarschijnlijk klein of afwezig. Wel kan specifieke visserij op kreeften en krabben zorgen voor een verstoring van de benthische biodiversiteit. Niet alle vergunde visserijvormen komen ook daadwerkelijk bij de oesterbank voor. De enige gebruikte vorm is het GNC-tuig (kieuwnet (omringend); gillnets (circling)) voor visserij op zeebaars en harders, die de oesterbank waarschijnlijk niet aantast. Om inzicht te krijgen in het bodemcontact van het net adviseren we een kleine proef uit te voeren met camera’s. Als visserijmaatregel voor bodemberoerende visserij worden drie bufferzones voorgesteld, gebaseerd op de dimensies van de vistuigen en methodes zoals gebruikt in de garnalenvisserij. De minimale bufferzone is 43 m rondom het oesterbank. Ervan uitgaande dat het rif zich mogelijk nog zal uitbreiden in de toekomst, stellen we ook bufferzones van 50 en 100 m voor