Search

Challenges associated with first feeding have impeded the intensive culture of larval Yellow Perch Perca flavescens. Live‐food enrichment with polyunsaturated fatty acids (PUFAs) can increase the growth and survival of larval fish, but this method has not been tested with Yellow Perch. This study includes two experiments that were meant to evaluate (1) the relative proportion of docosahexaenoic acid (DHA; 22:6[n‐3]) and arachidonic acid (ARA; 20:4[n‐6]) in enrichment emulsions and (2) the provision of PUFA emulsions in ethyl ester (EE) or triacylglycerol (TG) form on Yellow Perch growth and survival. Fish were provided with live rotifers Brachionus plicatilis and brine shrimp Artemia nauplii for the first 10 d of exogenous feeding within a specialized recirculating system (phase I). Fish were then transferred to flow‐through tanks and were fed Artemia nauplii for 3 d before gradually transitioning to a formulated starter diet (5–7 d; phase II). Fish size, growth, survival, swim bladder inflation rates, and lipid/fatty acid concentrations were evaluated after each phase. Overall, rotifers assimilated ARA in higher concentrations (23.3% of total fatty acids) than Artemia (0.6–0.7% of total fatty acids). Rotifers also tended to assimilate PUFAs better in EE form than in TG form (71.3% versus 66.5% Σn‐3 + n‐6 fatty acids). In the first experiment, fish from the ARA‐ and DHA‐enriched diet groups had greater swim bladder inflation rates (phase I) and growth rates (phase II) than the unenriched control group. In phase I of the second experiment, the EE enrichment group had a significantly faster growth rate than the TG enrichment group (specific growth rate: mean ± SD = 40.5 ± 0.9% and 36.6 ± 1.8%, respectively). Fatty acid composition of zooplankton was heavily influenced by enrichments, and fatty acid composition of larvae/juveniles reflected that of their live prey. The results of this study suggest that PUFA enrichment of live feeds can accelerate Yellow Perch growth and reduce the time spent in the critical period of early development. [ABSTRACT FROM AUTHOR]

Aims We explored whether a missed cohort of patients in the community with heart failure (HF) and left ventricular systolic dysfunction (LVSD) could be identified and receive treatment optimization through a primary care heart failure (PCHF) service. Methods and results PCHF is a partnership between Inspira Health, National Health Service Cardiologists and Medtronic. The PCHF service uses retrospective clinical audit to identify patients requiring a prospective face-to-face consultation with a consultant cardiologist for clinical review of their HF management within primary care. The service is delivered via five phases: (i) system interrogation of general practitioner (GP) systems; (ii) clinical audit of medical records; (iii) patient invitation; (iv) consultant reviews; and (v) follow-up. A total of 78 GP practices (864 194 population) have participated. In total, 19 393 patients' records were audited. HF register was 9668 (prevalence 1.1%) with 6162 patients coded with LVSD (prevalence 0.7%). HF case finder identified 9725 additional patients to be audited of whom 2916 patients required LVSD codes adding to the patient medical record (47% increase in LVSD). Prevalence of HF with LVSD increased from 0.7% to 1.05%. A total of 662 patients were invited for consultant cardiologist review at their local GP practice. The service found that within primary care, 27% of HF patients identified for a cardiologist consultation were eligible for complex device therapy, 45% required medicines optimization, and 47% of patients audited required diagnosis codes adding to their GP record. Conclusion A PCHF service can identify a missed cohort of patients with HF and LVSD, enabling the optimization of prognostic medication and an increase in device prescription. [ABSTRACT FROM AUTHOR]

Objective: Ensuring patients with Atrial fibrillation (AF) are appropriately anticoagulated across NHS Bedfordshire Clinical Commissioning Group (BCCG) with the primary goal of reducing AF-related strokes.Methods: With Inspira Health, BCCG adopted the Primary Care Atrial Fibrillation (PCAF) Service which is led by Consultant Cardiologists. PCAF uses retrospective clinical audit to identify patients who require prospective face-to-face review on the need for anticoagulation.Results: 34 GP practices participated covering a 376 311 population (80% of BCCG). 12 573 patients' medical records were audited. The initial AF register was 7301 patients (AF prevalence 1.9%) and an additional 265 patients were identified through AF casefinder resulting in an AF prevalence of 2.0%. From 7566 patients with AF, 5831 were already on anticoagulants (77.1%), with 50.5% (n = 2947) on VKA medications and 49.5% (n = 2884) on direct oral anticoagulants (DOACs). Of the DOAC patients, 595 (20.6%) required dosage review or up to date blood tests. Case notes were reviewed for 1735 patients not on anticoagulation, with 901 (51.9%) patients deemed not eligible for anticoagulation. This left 834 (48.1%) patients who were eligible for, but not on, anticoagulation. A further 407 (13.8%) patients currently taking VKA medications were deemed sup-optimal with regards to INR control with TTR < 65%. In total 1241 patients were invited for review by a Consultant Cardiologist at their local GP practice, with an attendance rate of 90%. From all face to face and virtual consultations, 908 patients had anticoagulants prescribed, changed, management of INRs improved or were in the process of being anticoagulated at the time of follow-up. From this we would expect 36.3 AF related strokes prevented and a cost saving to the NHS of £470 200 per year.Conclusion: Through comprehensive audit, BCCG have been able to ensure that patients with AF are appropriately anticoagulated in 80% of their catchment population. This has improved anticoagulation to prevent AF-related stroke. [ABSTRACT FROM AUTHOR]

Abstract: The sperm of Yellow Perch Perca flavescens of two different age‐classes, age 0 and 3, were cryopreserved using two different cryoprotectants (dimethylsulfoxide [DMSO] and methanol [MetOH]) with two freezing methods (pellet and vial). The viability and quality of the progenies obtained from fertilization with cryopreserved sperm were then examined. The motility of Walleye Sander vitreus sperm was examined following cryopreservation and ultraviolet (UV) irradiation, with the aim of using heterologous cryopreserved sperm to inseminate Yellow Perch eggs to ensure gynogenesis. The first experiment compared the motility of fresh sperm and pellet method cryopreserved sperm devoid of salmon seminal plasma. Despite the high motility of fresh sperm—75% and 100%—of males age 0 and 3, respectively, the postthaw motility of seminal plasma devoid cryopreserved sperm was 0%. The second experiment addressed the efficiency of pellet and vial freezing methods with DMSO and MetOH supplemented with salmon seminal plasma. Cryopreserved sperm was thawed and motility measured. Sperm motility was not significantly different between pellet (13.3 ± 10.4%) and vial (10.3 ± 12.9%) methods in the absence of sperm extender; however, sperm motility of the pellet method was further improved (20 ± 8.7%) with the addition of sperm extender after thawing, while motility of the vial method sperm (10 ± 7.1%) was not. Cryopreserved sperm was further evaluated based on fertilization rate and ultimate survival and growth of larvae and juveniles through 14 d posthatch. Effects of UV exposure on fresh and pellet method cryopreserved sperm following UV irradiation were also examined. The motility of control sperm cryopreserved with DMSO and MetOH, and UV‐exposed sperm cryopreserved with DMSO decreased from 100% motility before cryopreservation (fresh sperm) to 75% following cryopreservation, while UV‐exposed sperm cryopreserved with MetOH decreased from 100% to 50%. This experiment provides significant new data to improve the effectiveness of straightforward cryopreservation techniques for Yellow Perch. [ABSTRACT FROM AUTHOR]

Background Mortality results for elective abdominal aortic aneurysm (AAA) repair are published by the Vascular Society of Great Britain and Ireland. These mortality results are not currently risk-adjusted. The objective of this study was to develop a national risk prediction model for elective AAA repair. Methods Data for consecutive patients undergoing elective AAA repair from the National Vascular Database between April 2008 and March 2011 were analysed. Multiple logistic regression and backwards model selection were used for model development. The study outcome measure was in-hospital mortality. Model calibration and discrimination were assessed for all AAA repairs, and separately for open repair and endovascular aneurysm repair (EVAR) subgroups. Results There were 312 in-hospital deaths among 11 423 AAA repairs (2·7 (95 per cent confidence interval (c.i.) 2·4 to 3·0) per cent): 230 after 4940 open AAA repairs (4·7 (4·1 to 5·3) per cent) and 82 after 6483 EVARs (1·3 (1·0 to 1·6) per cent). Variables associated with in-hospital death included in the final model were: open repair, increasing age, female sex, serum creatinine level over 120 µmol/l, cardiac disease, abnormal electrocardiogram, previous aortic surgery or stent, abnormal white cell count, abnormal serum sodium level, AAA diameter and American Society of Anesthesiologists fitness grade. The area under the receiver operating characteristic (ROC) curve was 0·781 (95 per cent c.i. 0·756 to 0·806) with a bias-corrected value of 0·774. Model calibration was good ( P = 0·963) based on the Hosmer-Lemeshow goodness-of-fit test, (bias-corrected) calibration curves, risk group assessment and recalibration regression. Conclusion This multivariable model for elective AAA repair can be used to risk-adjust outcome analyses and provide patient-specific estimates of in-hospital mortality risk for open AAA repair or EVAR. [ABSTRACT FROM AUTHOR]

Background: There is no consensus on the best risk prediction model for mortality following elective abdominal aortic aneurysm (AAA) repair. The objective was to evaluate the performance of five risk prediction models using the UK National Vascular Database (NVD). Methods: Data on elective AAA repairs from the NVD between January 2008 and December 2010 were analysed. The models assessed were: Glasgow Aneurysm Score (GAS), Vascular Biochemical and Haematological Outcome Model (VBHOM), physiological component of the Vascular Physiological and Operative Severity Score for enUmeration of Mortality (V-POSSUM), Medicare and Vascular Governance North West (VGNW). Overall model discrimination and calibration in equally sized risk-group quintiles were assessed. Results: The study cohort included 10 891 patients undergoing elective AAA repair (median age 74 years, 87·3 per cent men). The in-hospital mortality rates following endovascular and open repair were 1·3 and 4·7 per cent respectively (2·9 per cent overall). The Medicare and VGNW models both showed good discrimination (area under receiver operating characteristic (ROC) curve 0·71), whereas the GAS, VBHOM and V-POSSUM models showed poor discrimination (area under ROC curve 0·60, 0·61 and 0·62 respectively). The VGNW model was the only one to predict the overall mortality rate in the cohort (3·3 per cent predicted versus 2·9 per cent observed; P = 0·066). The VGNW model demonstrated good calibration, predicting risk accurately in four risk-group quintiles. The Medicare, V-POSSUM and VBHOM models accurately predicted risk in three, two and no risk-group quintiles respectively. Conclusion: The Medicare and VGNW models contain similar risk factors and showed good discrimination when applied to the NVD. Both models would be suitable for risk prediction after elective AAA repair in the UK. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective Endoscopic vein harvesting (EVH) is increasingly used as an alternative to open vein harvesting (OVH) for coronary artery bypass graft (CABG) surgery. Concerns about the safety of EVH with regard to midterm clinical outcomes following CABG have been raised. The objective of this study was to assess the impact of EVH on short-term and midterm clinical outcomes following CABG. Design This was a retrospective analysis of prospectively collected multi-centre data. A propensity score was developed for EVH and used to match patients who underwent EVH to those who underwent OVH. Setting Blackpool Victoria Hospital, Plymouth Derriford Hospital and the University Hospital of South Manchester were the main study settings. Patients There were 4709 consecutive patients who underwent isolated CABG using EVH or OVH between January 2008 and July 2010. Main outcome measures The main outcome measure was a combined end point of death, repeat revascularisation or myocardial infarction. Secondary outcome measures included in-hospital morbidity, in-hospital mortality and midterm mortality. Results Compared to OVH, EVH was not associated with an increased risk of the main outcome measure at a median follow-up of 22 months (HR 1.15; 95% CI 0.76 to 1.74). EVH was also not associated with an increased risk of in-hospital morbidity, in-hospital mortality (0.9% vs 1.1%, p=0.71) or midterm mortality (HR 1.04; 95% CI 0.65 to 1.66). Conclusions This multi-centre study demonstrates that at a median follow-up of 22 months, EVH was not associated with adverse short-term or midterm clinical outcomes. However, before the safety of EVH can be clearly determined, further analyses of long-term clinical outcomes are required. [ABSTRACT FROM AUTHOR]

Outcome can be predicted [ABSTRACT FROM AUTHOR]

Objectives To assess the impact of introducing a transcatheter aortic valve implantation (TAVI) service on aortic valve surgical activity and outcomes. Design A retrospective analysis of prospectively collected data. Setting University hospital of south Manchester. Patients 815 consecutive patients undergoing isolated aortic valve replacement (AVR) or coronary artery bypass grafting plus AVR from January 2006 to December 2009. Fifty consecutive patients who underwent TAVI from January 2008 to December 2009. Main outcome measures Aortic valve surgical activity in the 2 years before the introduction of a TAVI service and in the 2 years following. Outcomes following conventional aortic valve surgery and TAVI. Results In the 2 years following the introduction of TAVI at this centre, conventional AVR activity has increased by 37% compared with an 8% increase nationally (p<0.001). Compared with the 2 years before TAVI there was no change in the mean logistic EuroSCORE (7.4 vs 7.9 p=0.16) or crude mortality rate (2.9% vs 2.1% p=0.48). Fifty high-risk patients underwent TAVI with a 30-day mortality rate of 0%. The mean logistic EuroSCORE of the TAVI patients was 25.3. Conclusions TAVI is an emerging alternative to AVR in high-risk patients. Since the introduction of a TAVI service at this centre, conventional AVR activity has increased. Despite a trend of increasing mean logistic EuroSCORE indicating that more complex cases are being undertaken, there has been a non-significant reduction in the crude mortality rate. Offering a TAVI service has a positive impact on the volume of conventional AVR surgical activity. [ABSTRACT FROM AUTHOR]

Background: Previous angiographic lesion classification systems were derived from analysis of outcomes and lesion complexity in the early stent era. Advances in equipment design and techniques have altered the association between lesion and target vessel characteristics and procedural outcome in modern percutaneous coronary intervention (PCI). We evaluated the precise relationship between lesion characteristics and technical outcome on a lesion by lesion basis in a large dataset. We developed a multivariate model to predict technical failure in PCI. Methods: Analysis of prospectively collected data on 10,800 lesions in 6,719 consecutive PCI cases between January 2000 and December 2004. Multivariate logistic regression was undertaken to identify predictors of angiographic outcome at each treated lesion (success/failure). Statistical model validation was carried out using data from a further 3,340 treated lesions in 1,940 consecutive cases. Results: Independent variables associated with an increased risk of technical failure included total occlusion, severe calcification, proximal vessel tortuosity >90 degrees, lesion in a degenerate vein graft, and lesion angulation ≥90 degrees. The receiver operating characteristics (ROC) curve for the predicted probability of technical failure was 0.85. Failure occurred in 2.2% of treated lesions in the validation set (ROC curve 0.82, model predicted 2.5%). Conclusions: We have re-evaluated the association between lesion characteristics and technical outcome in modern PCI. We have thereby developed a contemporary prediction model for angiographic outcome at each treated lesion. (J Interven Cardiol 2010;23:394–400) [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of diabetes on 2-year mortality in current PCI practice. Background: In patients with coronary artery disease undergoing revascularization, diabetes mellitus is associated with higher mortality. Methods: A retrospective analysis was done of all patients undergoing PCI at our tertiary center between January 2000 and December 2004. There were 6,160 PCI procedures performed in 5,759 patients who received at least one stent. Of these patients, 801 (13.9%) were diabetic and 4,958 (86.1%) were nondiabetic. The primary outcome measure of the study was all-cause mortality. All patients were followed up for a period of 2 years. Multivariate logistic regression analysis was used to test for a potential independent association between diabetic status and follow-up mortality. Results: Before adjustment, a trend toward higher mortality was observed in diabetic patients compared to non-diabetics at 1 year (3.2% vs 2.4%) and 2 years (5.1% vs 3.8%), P = 0.12. Independent predictors for mortality were increasing age, renal dysfunction, peripheral vascular disease, NYHA class >2, urgent PCI, treating left main stem lesions, vessel diameter ≤ 2.5 mm, and 3-vessel disease. The use of drug-eluting stent was associated with a reduction in mortality. Diabetes was found to have no independent impact on mortality following PCI (odds ratio = 1.08; 95% confidence intervals = 0.73–1.60; P = 0.71). Conclusion: The presence of diabetes was not an independent predictor of mortality following PCI. A diabetic patient that does not require insulin treatment and has no evidence of macro- or microvascular diabetic disease could enjoy a PCI outcome similar to nondiabetic subjects. [ABSTRACT FROM AUTHOR]

Objectives: To compare implications of using the logistic EuroSCORE and a locally derived model when analysing individual surgeon mortality outcomes. Design: Retrospective analysis of prospectively collected data. Setting: All NHS hospitals undertaking adult cardiac surgery in northwest England. Patients: 14 637 consecutive patients, April 2002 to March 2005. Main outcome measures: We have compared the predictive ability of the logistic EuroSCORE (uncalibrated), the logistic EuroSCORE calibrated for contemporary performance and a locally derived logistic regression model. We have used each to create risk-adjusted individual surgeon mortality funnel plots to demonstrate high mortality outcomes. Results: There were 458 (3.1%) deaths. The expected mortality and receiver operating characteristic (ROC) curve values were: uncalibrated EuroSCORE -5.8% and 0.80, calibrated EuroSCORE -3.1% and 0.80, locally derived model -3.1% and 0.82. The uncalibrated EuroSCORE plot showed one surgeon to have mortality above the northwest average, and no surgeon above the 95% control limit (CL). The calibrated EuroSCORE plot and the local model showed little change in surgeon ranking, but significant differences in identifying high mortality outcomes. Two of three surgeons above the 95% CL using the calibrated EuroSCORE revert to acceptable outcomes when the local model is applied but the finding is critically dependent on the calibration coefficient. Conclusions: The uncalibrated EuroSCORE significantly overpredicted mortality and is not recommended. Instead, the EuroSCORE should be calibrated for contemporary performance. The differences demonstrated in defining high mortality outcomes when using a model built for purpose suggests that the choice of risk model is important when analysing surgeon mortality outcomes. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to document what proportion of patients referred for consideration of cardiac surgery are turned down, the reasons given for not operating and also to evaluate what happens to those patients who do not undergo surgery. Methods: 382 elective patients referred for consideration of cardiac surgery to one of six consultant cardiac surgeons at Wythenshawe Hospital during a one year period from were included in the study. Data for those patients who underwent an operation were collected prospectively in a cardiac surgery database. The case notes of those patients who did not undergo an operation were reviewed to establish reasons given by surgeons for not operating. Patients were followed up to determine vital status at the end of the study period. Results: 333 (87.2%) patients underwent an operation and 49 (12.8%) did not. 68% of patients turned down were thought to be too high-risk. 14% of patients did not fulfill symptomatic or prognostic criteria for surgery and in 8% of patients coronary artery surgery was thought ineffective due to poor distal vessels. 6% of patients declined an operation and 4% were thought to be more suitable for coronary angioplasty. Patients turned down for surgery had more renal dysfunction (p = 0.017), respiratory disease (p < 0.001) and peripheral vascular disease (p < 0.001), were more likely to have undergone prior heart surgery (p < 0.001) and to have poor left ventricular function (p = 0.003). Patients turned down for surgery had significantly higher EuroSCORE values compared to patients who underwent an operation: 5 versus 4 (p = 0.006). Freedom from death in the patients turned down for surgery at 1-, 6-, 12- and 24-months was 95.9%, 91.8%, 83.7% and 71.4% respectively, compared with 97.9%, 96.7%, 96.4% and 94.5% for the patients who underwent an operation (p < 0.001 [log-rank]). 14 of the 15 deaths that occurred in the turned down group occurred in the category considered too high-risk for surgery. Conclusion: 12.8% of patients referred for consideration of cardiac surgery did not undergo an operation. Two thirds of patients not accepted for surgery were thought too high risk. Those patients who did not undergo an operation had a significantly worse mortality. [ABSTRACT FROM AUTHOR]

Objectives: To study changes in coronary artery surgery practice in the years spanning publication of cardiac surgery mortality data in the UK. Methods: A retrospective analysis of prospectively collected data from all National Health Service centres undertaking adult cardiac surgery in northwest England was carried out. Patients undergoing coronary artery surgery for the first time between April 1997 and March 2005 were included. Changes in observed, predicted and risk adjusted mortality (EuroSCORE) were studied. Evidence of risk-averse behaviour was looked for by examining the number of patients at low risk (EuroSCORE 0-5), high risk (6-10), and very high risk (11 or more), before and after public disclosure. Results: 25 730 patients underwent coronary artery surgery during the study period. The observed mortality decreased from 2.4% in 1997-8 to 1.8% in 2004-5 (p=0.014). The expected mortality (EuroSCORE) increased from 3.0 to 3.5 (p<0.001). The observed to expected mortality ratio decreased from 0.8 to 0.51 (p<0.05). The total number and percentage of patients who were at low risk, high risk and very high risk was 2694 (84.6%), 449 (14.1%) and 41(1.3%) before and 2654 (81.7%), 547 (16.8%) and 47(1.4%) after public disclosure, respectively, demonstrating a significant increase in the number and proportion of high risk patients undergoing surgery (p<0.001). Conclusions: Publication of cardiac surgery mortality data in the UK has been associated with decreased risk adjusted mortality on retrospective analysis of a large patient database. There is no evidence that fewer high risk patients are undergoing surgery because mortality rates are published. [ABSTRACT FROM AUTHOR]

Objectives: To study the ability of the logistic EuroSCORE to predict operative risk in contemporary cardiac surgery. Design: Retrospective analysis of prospectively collected data. Setting: All National Health Service centres undertaking adult cardiac surgery in northwest England. Patients: All patients undergoing cardiac surgery between April 2002 and March 2004. Main outcome measures: The predictive ability of the logistic EuroSCORE was assessed by analysing how well it discriminates between patients with differing observed risk by using the area under the receiver operating characteristic (ROC) curve and studying how well it is calibrated against observed in-hospital mortality. The performance of the EuroSCORE was examined in the following surgical subgroups: all cardiac surgery, isolated coronary artery surgery, isolated valve surgery, combined valve and coronary surgery, mitral valve surgery, aortic valve surgery and other surgery. Results: 9995 patients underwent surgery. The discrimination of the logistic EuroSCORE was good with a ROC curve area of 0.79 for all cardiac surgery (range 0.71–0.79 in the subgroups). For all operations, the predicted mortality was 5.7% and observed mortality was 3.3%. The logistic EuroSCORE overpredicted observed mortality for all subgroups but by differing degrees (p = 0.02) Conclusions: The logistic EuroSCORE is a reasonable overall predictor for contemporary cardiac surgery but overestimates observed mortality. Its accuracy at predicting risk in different surgical subgroups varies. The logistic EuroSCORE should be recalibrated before it is used to gain reassurance about outcomes. Caution should be exercised when using it to compare hospitals or surgeons with a different operative case mix. [ABSTRACT FROM AUTHOR]

Objective: To develop a multivariate prediction model for major adverse cardiac events (MACE) after percutaneous coronary interventions (PCIs) by using the North West Quality Improvement Programme in Cardiac Interventions (NWQIP) PCI Registry. Setting: All NHS centres undertaking adult PCIs in north west England. Methods: Retrospective analysis of prospectively collected data on 9914 consecutive patients undergoing adult PCI between 1 August 2001 and 31 December 2003. A multivariate logistic regression analysis was undertaken, with the forward stepwise technique, to identify independent risk factors for MACE. The area under the receiver operating characteristic (ROC) curve and the Hosmer-Lemeshow goodness of fit statistic were calculated to assess the performance and calibration of the model, respectively. The statistical model was internally validated by using the technique of bootstrap resampling. Main outcome measures: MACE, which were in-hospital mortality, Q wave myocardial infarction, emergency coronary artery bypass graft surgery, and cerebrovascular accidents. Results: Independent variables identified with an increased risk of developing MACE were advanced age, female sex, cerebrovascular disease, cardiogenic shock, priority, and treatment of the left main stem or graft lesions during PCI. The ROC curve for the predicted probability of MACE was 0.76, indicating a good discrimination power. The prediction equation was well calibrated, predicting well at all levels of risk. Bootstrapping showed that estimates were stable. Conclusions: A contemporaneous multivariate prediction model for MACE after PCI was developed. The NWQIP tool allows calculation of the risk of MACE permitting meaningful risk adjusted comparisons of performance between hospitals and operators. [ABSTRACT FROM AUTHOR]

Background: Little is known about the effect of surgical training on outcomes in thoracic surgery. The impact of surgeon training on outcomes following lung resection was examined, focusing on lobectomy as a marker operation. Methods: 328 consecutive patients who underwent lobectomy at our institution between 1 October 2001 and 30 June 2003 were studied. Data were collected prospectively during the patient's admission as part of routine clinical practice and validated by a designated audit officer. Patient characteristics and postoperative outcomes were compared between trainee led and consultant led operations. Results: In 115 cases (35.1%) the operation was performed by a trainee thoracic surgeon as the first operator. There were no significant differences in patient characteristics between the two groups. In- hospital mortality was similar for operations led by trainees and consultants (3.5% and 2.8%, respectively; p>0.99). Outcomes in the two groups did not differ significantly with respect to respiratory, cardiovascular, renal, neurological, chest infection, bleeding, and gastrointestinal complications. Survival rates at 1 year were 82.6% for procedures led by trainees compared with 81.7% for procedures led by consultants (p=0.83). Conclusions: With appropriate supervision, trainee thoracic surgeons can perform lobectomies safely without compromising short or intermediate term patient outcome. [ABSTRACT FROM AUTHOR]

Objective: To assess the cost effectiveness of drug eluting stents (DES) compared with conventional stents for treatment of symptomatic coronary artery disease in the UK. Design: Cost-utility analysis of audit based patient subgroups by means of a simple economic model. Setting: Tertiary care. Participants: 12 month audit data for 2884 patients receiving percutaneous coronary intervention with stenting at the Cardiothoracic Centre Liverpool between January 2000 and December 2002. Main outcome measures: Risk of repeat revascularisation within 12 months of index procedure and reduction in risk from use of DES. Economic modelling was used to estimate the cost-utility ratio and threshold price premium. Results: Four factors were identified for patients undergoing elective surgery (n = 1951) and two for non- elective surgery (n = 933) to predict risk of repeat revascularisation within 12 months. Most patients fell within the subgroup with lowest risk (57% of the elective surgery group with 5.6% risk and 91% of the non-elective surgery group with 9.9% risk). Modelled cost-utility ratios were acceptable for only one group of high risk patients undergoing non-elective surgery (only one patient in audit data). Restricting the number of DES for each patient improved results marginally: 4% of stents could then be drug eluting on economic grounds. The threshold price premium justifying 90% substitution of conventional stents was estimated to be £112 (US$212, &3x20AC;162) (sirolimus stents) or £89 (US$167, &3x20AC;130) (paclitaxel stents). Conclusions: At current UK prices, DES are not cost effective compared with conventional stents except for a small minority of patients. Although the technology is clearly effective, general substitution is not justified unless the price premium falls substantially. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation can occur in up to 40% of patients undergoing coronary surgery. Methods: We retrospectively analysed 103 consecutive coronary surgery patients under the care of one surgeon between April 2003 and September 2003. These patients received 40 mg of sotalol orally twice daily from the first post-operative day for 6 weeks and 2 g of magnesium intravenously immediately post surgery and on the first post-operative day. We developed a propensity score for the probability of receiving sotalol and magnesium after coronary surgery. 89 patients from the sotalol and magnesium group were successfully matched with 89 unique coronary surgery patients who did not receive either sotalol or magnesium with an identical propensity score. Results: Preoperative characteristics were well matched between groups. There was no significant difference with respect to in-hospital mortality between groups (sotalol and magnesium 1.1% versus control 4.5%; p = 0.17). The incidence of atrial fibrillation in the sotalol and magnesium group was 13.5% compared to 27.0% in the controls (p = 0.025). Conclusion: The combination of sotalol and magnesium can significantly reduce the incidence of post-operative atrial fibrillation following coronary surgery. [ABSTRACT FROM AUTHOR]

Background: The relationship between cardiac enzyme (CE) release following coronary artery bypass surgery (CABG) and medium term outcome is unclear. We sought to determine the relationship between post-operative CE release and one-year survival following isolated CABG. Methods: Over three years 3,024 consecutive patients underwent isolated CABG. Patient characteristics were prospectively recorded in a cardiac surgical database. CE release, taken as the highest single measurement recorded in the first 24 hours post-op, was abstracted from an electronic archive. All cause mortality was taken from a national registry of deaths. Results: Data were complete for 2,860 (94.6%) patients. CK-MB isoenzyme (reference range 5-24 U/l) was recorded in 2,568 (89.8%), total CK in 292 (10.2%). CE release three or more times the upper limit of the reference range (ULR) were recorded in 498 (17.4%) patients, 163 (5.7%) patients had CE more than six times ULR. There were 122 deaths (4.3%). Cox proportional hazards analysis showed that CE release 3-6 times ULR (adjusted HR 2.1 [95% CI: 1.6 to 2.6], p = 0.002) and CE release six or more times the ULR (adjusted HR 5.0 [95% CI: 4.5 to 5.4], p < 0.001) were independently associated with increased one-year mortality. Conclusion: Cardiac enzyme release following CABG is associated with increased one-year allcause mortality. The definition of peri-operative myocardial infarction following CABG should include elevation of CK-MB three or more times the upper limit of normal. [ABSTRACT FROM AUTHOR]

Objective: Patients who have prolonged stay in intensive care unit (ICU) are associated with adverse outcomes. Such patients have cost implications and can lead to shortage of ICU beds. We aimed to develop a preoperative risk prediction tool for prolonged ICU stay following coronary artery surgery (CABG). Methods: 5,186 patients who underwent CABG between 1st April 1997 and 31st March 2002 were analysed in a development dataset. Logistic regression was used with forward stepwise technique to identify preoperative risk factors for prolonged ICU stay; defined as patients staying longer than 3 days on ICU. Variables examined included presentation history, co-morbidities, catheter and demographic details. The use of cardiopulmonary bypass (CPB) was also recorded. The prediction tool was tested on validation dataset (1197 CABG patients between 1st April 2003 and 31st March 2004). The area under the receiver operating characteristic (ROC) curve was calculated to assess the performance of the prediction tool. Results: 475(9.2%) patients had a prolonged ICU stay in the development dataset. Variables identified as risk factors for a prolonged ICU stay included renal dysfunction, unstable angina, poor ejection fraction, peripheral vascular disease, obesity, increasing age, smoking, diabetes, priority, hypercholesterolaemia, hypertension, and use of CPB. In the validation dataset, 8.1% patients had a prolonged ICU stay compared to 8.7% expected. The ROC curve for the development and validation datasets was 0.72 and 0.74 respectively. Conclusion: A prediction tool has been developed which is reliable and valid. The tool is being piloted at our institution to aid resource management. [ABSTRACT FROM AUTHOR]

Background and Objectives The purpose of this work was to describe the methodology used to build a transfusion database that allows continuous audit of transfusion practices in coronary artery bypass surgery. Materials and Methods The transfusion database requires electronic data available from two sources: the hospital's patient administration system; and the local blood transfusion service. Results We demonstrated a reduction in the percentage of patients receiving red blood cell transfusion: from 47·4% in 1997/1998 to 31·6% in 2001/2002 (P < 0·001). Reductions have also been shown in the percentage of patients receiving fresh-frozen plasma and platelet units. Conclusions The data sourcing the transfusion database should be available to all hospitals through their patient administration systems and local blood transfusion service. Its use can help to reduce transfusion rates significantly. [ABSTRACT FROM AUTHOR]

Abstract Objective As a result of recent failures in clinical governance the government has made a commitment to bring individual surgeons' mortality data into the public domain. We have analysed a database to compare crude mortality after coronary artery bypass surgery with outcomes that were stratified by risk. Design Retrospective analysis of prospectively collected data. Setting All NHS centres in the geographical north west of England that undertake cardiac surgery in adults. Participants All patients undergoing isolated bypass graft surgery for the first time between April 1999 and March 2002. Main outcome measures Surgeon specific postoperative mortality and predicted mortality by EuroSCORE. Results 8572 patients were operated on by 23 surgeons. Overall mortality was 1.7%. Observed mortality between surgeons ranged from 0% to 3.7%; predicted mortality ranged from 2% to 3.7%. Eighty five per cent (7286) of the patients had a EuroSCORE of 5 or less; 49% of the deaths were in this lower risk group. A large proportion of the variability in predicted mortality between surgeons was due to a small but differing number of high risk patients. Conclusions It is possible to collect risk stratified data on all patients undergoing coronary bypass surgery. For most the predicted mortality is low. The small proportion of high risk patients is responsible for most of the differences in predicted mortality between surgeons. Crude comparisons of death rates can be misleading and may encourage surgeons to practise risk averse behaviour. We recommend a comparison of death rates that is stratified by risk and based on low risk cases as the national benchmark for assessing consultant specific performance. [ABSTRACT FROM AUTHOR]

Objective To study the "learning curve" associated with independent practice in coronary artery surgery. Design Retrospective analysis of prospectively collected data. Setting All NHS centres in north west England that carry out cardiac surgery in adults. Participants 18,913 patients undergoing coronary artery surgery for the first time between April 1997 and March 2003, 5678 of whom were operated on by 15 surgeons in the first four years after their consultant appointment. Main outcome measures Observed and predicted mortality (EuroSCORE)for surgeons in their first, second, third, and fourth years after appointment as a consultant compared with figures for established surgeons. Results Overall mortality decreased over the six years of study (P =0.01). Of the patients operated on by established surgeons or newly appointed consultants, 265/13 235 (2.0%) and 109/5678 (1.9%), respectively, died (P =0.71). There was a progressive decrease in observed mortality with time after appointment as a consultant from 2.2% in the first year to 1.2% in the fourth year (P =0.049). This result remained significant after adjustment for time and case mix (P =0.019). Conclusions Mortality in patients operated on by newly appointed consultant surgeons is similar to mortality in patients operated on by established surgeons. There are significant decreases in crude and risk adjusted mortality in the four years after appointment. These findings should influence the nature of practice in newly appointed surgeons. [ABSTRACT FROM AUTHOR]

Follow-up examinations were done on 598 plantar wart sites treated by radiation 3 to 28 years earlier. In 45 cases, minor skin changes were delectable. There were no frank radiation sequelae. Of three X-ray schedules used, a one-dose method is recommended of its simplicity, efficacy and safety. [ABSTRACT FROM AUTHOR]

A letter to the editor in response to the article related to patient selection in endoscopic vein harvesting is presented and also presents a response from the author.

A letter to the editor is presented in response to a study on logistic risk model for mortality following elective abdominal aortic aneurysm repair that appeared in a 2011 issue of the journal.

Background: The aim of this study was to document what proportion of patients referred for consideration of cardiac surgery are turned down, the reasons given for not operating and also to evaluate what happens to those patients who do not undergo surgery.Methods: 382 elective patients referred for consideration of cardiac surgery to one of six consultant cardiac surgeons at Wythenshawe Hospital during a one year period from were included in the study. Data for those patients who underwent an operation were collected prospectively in a cardiac surgery database. The case notes of those patients who did not undergo an operation were reviewed to establish reasons given by surgeons for not operating. Patients were followed up to determine vital status at the end of the study period.Results: 333 (87.2%) patients underwent an operation and 49 (12.8%) did not. 68% of patients turned down were thought to be too high-risk. 14% of patients did not fulfill symptomatic or prognostic criteria for surgery and in 8% of patients coronary artery surgery was thought ineffective due to poor distal vessels. 6% of patients declined an operation and 4% were thought to be more suitable for coronary angioplasty. Patients turned down for surgery had more renal dysfunction (p = 0.017), respiratory disease (p < 0.001) and peripheral vascular disease (p < 0.001), were more likely to have undergone prior heart surgery (p < 0.001) and to have poor left ventricular function (p = 0.003). Patients turned down for surgery had significantly higher EuroSCORE values compared to patients who underwent an operation: 5 versus 4 (p = 0.006). Freedom from death in the patients turned down for surgery at 1-, 6-, 12- and 24-months was 95.9%, 91.8%, 83.7% and 71.4% respectively, compared with 97.9%, 96.7%, 96.4% and 94.5% for the patients who underwent an operation (p < 0.001 [log-rank]). 14 of the 15 deaths that occurred in the turned down group occurred in the category considered too high-risk for surgery.Conclusion: 12.8% of patients referred for consideration of cardiac surgery did not undergo an operation. Two thirds of patients not accepted for surgery were thought too high risk. Those patients who did not undergo an operation had a significantly worse mortality. [ABSTRACT FROM AUTHOR]

This article focuses on a study related to operator specific outcome in percutaneous coronary intervention (PCI) and impact of risk adjustment on apparent mace rate. Publication of operator specific outcomes in PCI is likely to replace centre specific major adverse cardiac event data currently audited by BCIS. Researchers examined the use of risk adjustment techniques in the comparison of outcomes between operators. Crude outcome data can suggest significant differences in operator outcome that appears to be related to differences in case mix.